"What you Say Matters": Review of Clinical Outcome of Advanced Medical Directives Between Cancer and Non-cancer Patients in a Chinese Culture Society.

INTRODUCTION: Advance medical directives (AMD) are statements made by individuals indicating the life-sustaining treatment that they would refuse in the future when they lost their mental capacity for medical decisions. While the proposal for the AMD legislation is ongoing locally in Hong Kong SAR, there are limited reviews on the clinical outcomes associated with it. OBJECTIVE: To provide a comprehensive review on clinical outcomes of signed AMD. METHODOLOGY: Retrospective, multi-center study, which includes AMD signed within five cluster hospitals. Records of signed AMD from 1st JAN 2020 to 31st DEC 2022 were retrieved from a central registry. Clinical information of each patient was obtained from the electronic patient record. RESULT: 456 patients with documented AMD were included in the study. 91.6% of AMD were signed by palliative care (PC) team. Majority (74.6%) of the patients were accompanied by family members or friends when AMD were signed. The concordance rate between the AMD and the medical care received was 89.5%. No patient revoked their AMD. Cancer and non-cancer patients showed similar rates of AMD concordance, frequency of Accident & Emergency Department (AED) visits or acute ward admissions, duration of hospital stays in the 30 days before death, and prevalence of receiving invasive or intensive treatments. CONCLUSION: Our study demonstrated that PC team currently plays a pivotal role in AMD completion, and AMD remains important in ensuring patients' care preferences are executed across different medical conditions. With the upcoming AMD legislation in Hong Kong SAR, adequate promotion and education should be launched.

Knowledge, attitudes and intention on fertility preservation among breast cancer patients.

Breast cancer is the most common cancer in reproductive age women. The aim of this study is to assess the knowledge, attitude and intention on fertility preservation among women diagnosed to have breast cancer. This is a multi-centre cross-sectional questionnaire study. Reproductive age women diagnosed with breast cancer attending Oncology, Breast Surgery and Gynaecology Clinics and support groups were invited to participate. Women filled in paper or electronic form of the questionnaire. 461 women were recruited and 421 women returned the questionnaire. Overall, 181/410 (44.1%) women had heard of fertility preservation. Younger age and higher education level were significantly associated with increased awareness of fertility preservation. Awareness and acceptance of the different fertility preservation methods in reproductive age women with breast cancer was suboptimal. However, 46.1% women felt that their fertility concerns affected their decision for cancer treatment in some way.

Consensus Statements on Precision Oncology in the China Greater Bay Area.

BACKGROUND: Next-generation sequencing comprehensive genomic panels (NGS CGPs) have enabled the delivery of tailor-made therapeutic approaches to improve survival outcomes in patients with cancer. Within the China Greater Bay Area (GBA), territorial differences in clinical practices and health care systems and strengthening collaboration warrant a regional consensus to consolidate the development and integration of precision oncology (PO). Therefore, the Precision Oncology Working Group (POWG) formulated standardized principles for the clinical application of molecular profiling, interpretation of genomic alterations, and alignment of actionable mutations with sequence-directed therapy to deliver clinical services of excellence and evidence-based care to patients with cancer in the China GBA. METHODS: Thirty experts used a modified Delphi method. The evidence extracted to support the statements was graded according to the GRADE system and reported according to the Revised Standards for Quality Improvement Reporting Excellence guidelines, version 2.0. RESULTS: The POWG reached consensus in six key statements: harmonization of reporting and quality assurance of NGS; molecular tumor board and clinical decision support systems for PO; education and training; research and real-world data collection, patient engagement, regulations, and financial reimbursement of PO treatment strategies; and clinical recommendations and implementation of PO in clinical practice. CONCLUSION: POWG consensus statements standardize the clinical application of NGS CGPs, streamline the interpretation of clinically significant genomic alterations, and align actionable mutations with sequence-directed therapies. The POWG consensus statements may harmonize the utility and delivery of PO in China's GBA.

A retrospective review for the use of palliative sedation in a regional hospital in Hong Kong.

BACKGROUND: Palliative sedation is defined as monitored use of medication intended to induce a state of decreased or absent awareness to relieve intractable suffering in a manner that is ethically acceptable to the patient, family, and health-care providers. The prevalence of palliative sedation reported ranges from 10% to 50% during in end of life care setting. There was no major review performed on the prevalence and practice of palliative sedation in Hong Kong. Besides, published guidelines and medication recommendations are developed in Caucasian settings, which may not be taken into account the cultural aspect in Chinese. Therefore, we would like to review our practice in caring terminal cancer patients to report the prevalence and practice of palliative sedation and to review factors associated with successful sedation in this group of patients. METHODS: One-hundred and eighty consecutive patients with histological or radiological evidence of malignancy who died in palliative care ward from 1st July to 30th September 2017 were screened. All patients who received continuous midazolam infusion were included. Patients' demographic data, cancer disease status, laboratory results and interview records were retrieved from electronic patient records and in-patient hospital notes. The reason for sedation, background and concurrent symptoms during sedation, and the clinical notes on symptom control during the sedation period were all reviewed. All the drug records including the dose of midazolam and other concomitant drugs, duration of palliative sedation as well as the depth of sedation were assessed. Survival data estimated from the day of admission to our department until death were recorded. RESULTS: Three hundred and thirty-nine patient-days, contributed by 81 patients out of 180 patients (45%), with midazolam infusion were studied. There was no statistical difference in the baseline characteristics of both patient groups. Median survival since admission to oncology ward in the sedated group was 11 versus 9 days in the non-sedated group (P=0.65). The median time for patients on sedation was 32.33 hours (range, 2.91-1,240 hours). Dyspnea was the most common cause of palliative sedation (78.0%), followed by delirium (40.9%). The mean dose of midazolam infusion was 10 milligram per day (range, 5-45 mg). Deranged liver function was the only statistically significant factor associated with successful sedation after multivariate analysis. CONCLUSIONS: The use of palliative sedation is safe and effective in managing refractory symptoms and is not associated with worsening of survival. Deranged liver function was associated with better symptom control. The dose of midazolam and haloperidol needed for adequate symptom control were lower than suggested in Western guidelines. Further studies on the dose requirement in Chinese population are warranted. Establishing consensus and guidelines on palliative sedation in Hong Kong should be the way forward to ensure quality care to this group of patients.