Cancer cachexia: A scoping review on non-pharmacological interventions.

Objective: Cancer cachexia occurs in 30%-80% of patients, increasing morbidity and mortality and impacting the health-related quality of life also for caregivers. Pharmacological interventions have been studied but have shown inconsistent effects on patients' lives in terms of relative outcomes and poor adherence to pharmacological treatment. We provide an overview of the evidence on non-pharmacological interventions for cancer cachexia. Methods: We conducted a scoping review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for scoping review (PRISMA-ScR). On September 21, 2022, plus an update on January 10, 2024, we searched MEDLINE, Embase, CINAHL, Cochrane, PsycINFO, and Scopus for 2012-2024. We excluded pharmacological interventions defined as "any substance, inorganic or organic, natural or synthetic, that can produce functional modifications, through a chemical, physicochemical or physical action." Results: The search retrieved 9308 articles, of which 17 were eligible. Non-pharmacological interventions included nutritional counseling, complementary therapies (acupuncture), rehabilitation, and psychoeducational/psychosocial support. The data showed small and heterogeneous samples and different disease localization and stages. Thirty-nine percent were multimodal interventions and aimed at patients, not families. The common primary outcomes were body weight and composition, biomarkers, quality of life, psychological suffering, and muscular strength. Only three studies focus on the patient-caregiver dyad. Conclusions: Interventions on cancer cachexia should be multimodal and multiprofessional, proposed early, and aimed at quality of life outcomes. The caregiver's involvement is essential. Nurses can play an active role in managing cancer cachexia. More well-designed studies are needed to understand the efficacy and contents of non-pharmacological interventions. Systematic review registration: The review protocol has been registered in the OSF registry (DOI: 10.17605/OSF.IO/H4A29).

The meaning of dignity in care during the COVID-19 pandemic: a qualitative study in acute and intensive care.

BACKGROUND: The pandemic Era has forced palliative care professionals to use a dignity-in-care approach in different settings from the classic ones of palliative care: acute and intensive care. We explored the meanings of dignity for patients, their family members, and clinicians who have experienced COVID-19 in the acute and intensive care setting. METHODS: A qualitative, prospective study by means of semi-structured interviews with patients hospitalized for COVID-19, family members, and clinicians who care for them. FINDINGS: Between March 2021 and October 2021, we interviewed 16 participants: five physicians, three nurses, and eight patients. None of the patients interviewed consented for family members to participate: they considered it important to protect them from bringing the painful memory back to the period of their hospitalization. Several concepts and themes arose from the interviews: humanity, reciprocity, connectedness, and relationship, as confirmed by the literature. Interestingly, both healthcare professionals and patients expressed the value of informing and being informed about clinical conditions and uncertainties to protect dignity. CONCLUSIONS: Dignity should be enhanced by all healthcare professionals, not only those in palliative care or end-of-life but also in emergency departments.

Psycho-Educational and Rehabilitative Intervention to Manage Cancer Cachexia (PRICC) for Advanced Patients and Their Caregivers: Lessons Learned from a Single-Arm Feasibility Trial.

BACKGROUND: Key elements in cancer cachexia (CC) management are personalized and multimodal interventions, but it is hard for some patients to follow programs based on several components. We examined the feasibility of a bimodal intervention, including a psycho-educational component and exercises, to support patients and their caregivers in managing CC; Methods: Prospective mixed-methods pilot study explored feasibility data, changes in patient-reported outcomes, and performance outcomes over time in a convenient sample of 30 consecutive CC patients and their caregivers. RESULTS: Twenty-four dyads consented to participate. Twenty dyads received at least two psycho-educational sessions, so the psycho-educational component was feasible for 83.3% of the sample. Six dyads participated in at least fourteen out of twenty-seven rehabilitation sessions, so the exercise program was feasible for 25.0% of the sample. Six dyads showed compliance greater than 50% for both components of the bimodal intervention. CONCLUSIONS: While we did not meet our primary feasibility endpoint and had mixed acceptability, our experience provides insight into the challenges and lessons learned in implementing a primary palliative care intervention for CC. More robust studies are needed to help clinicians understand the best exercise program for CC patients, to be included in a multimodal intervention.

Dignity Therapy Training for the Healthcare Professionals: Lessons Learned From an Italian Experience.

Introduction: Dignity therapy (DT) is brief psychotherapy targeting psychological and existential suffering among patients with a life-limiting illness. Studies have been conducted on the use of DT by healthcare professionals. In Italy, the current legislation defines that any form of psychotherapy may be performed exclusively by psychotherapists. Consequently, this intervention is unlikely to be used by other healthcare professionals. Herein, we will describe a training on DT not as a psychotherapy intervention but as a narrative intervention for non-psychotherapists health care professionals. Finally, we will explore the potential enablers/barriers as experienced by palliative care physicians and nurses. Methods: The study was conducted in the Psycho-Oncology Unit within the Cancer Research Hospital of Reggio Emilia (Italy). It consisted of an exploratory qualitative case study. Data were collected employing observations and interview data and thematically analyzed. Results: The training was attended by six physicians and ten nurses and took place during two-afternoon sessions for 10 h. Two participants put their training into practice and administered DT under the supervision of a psychotherapist. Data analysis highlighted five overarching themes relating to the training experience and direct use of DT, namely, (i) time required, (ii) psychological skills, (iii) patient's disease awareness, (iv) patient's life history, and (v) distinguishing DT from Advance Care Planning. Conclusion: Palliative care professionals found DT to be a valuable non-pharmacological hospital-based intervention to address the person beyond the patient and his clinical conditions. In our experience, considering that in Italy, psychotherapy is an intervention that psychotherapists can only perform, it can help organize different training on DT for psychotherapists and other healthcare professionals.

Self-Care as a Method to Cope With Suffering and Death: A Participatory Action-Research Aimed at Quality Improvement.

Introduction: Palliative care is an emotionally and spiritually high-demanding setting of care. The literature reports on the main issues in order to implement self-care, but there are no models for the organization of the training course. We described the structure of training on self-care and its effects for a Hospital Palliative Care Unit. Method: We used action-research training experience based mostly on qualitative data. Thematic analysis of data on open-ended questions, researcher's field notes, oral and written feedback from the trainer and the participants on training outcomes and satisfaction questionnaires were used. Results: Four major themes emerged: (1) "Professional role and personal feelings"; (2) "Inside and outside the team"; (3) "Do I listen to my emotions in the care relationship?"; (4) "Death: theirs vs. mine." According to participants' point of view and researchers' observations, the training course resulted in ameliorative adjustments of the program; improved skills in self-awareness of own's emotions and sharing of perceived emotional burden; practicing "compassionate presence" with patients; shared language to address previously uncharted aspects of coping; allowing for continuity of the skills learned; translation of the language learned into daily clinical practices through specific facilitation; a structured staff's support system for emotional experiences. Discussion: Self-care is an important enabler for the care of others. The core of our intervention was to encourage a meta-perspective in which the trainees developed greater perspicacity pertaining to their professional role in the working alliance and also recognizing the contribution of their personal emotions to impasse experienced with patients.

Psychoeducational and rehabilitative intervention to manage cancer cachexia (PRICC) for patients and their caregivers: protocol for a single-arm feasibility trial.

INTRODUCTION: Half of all patients with cancer experience cachexia, with the prevalence rising above 80% in the last weeks of life. Cancer cachexia (CC) is a complex relational experience that involves the patient-family dyad. There are no studies on the association between the psychoeducational component and the rehabilitative component of dyads for supporting more functional relationships in the management of CC.The primary objective of this study is to evaluate the feasibility of a psychoeducational intervention combined with a rehabilitative intervention on dyads.The secondary objective is to improve the quality of life (QoL) and acceptability of the intervention. METHODS AND ANALYSIS: This mixed-methods study with a nonpharmacological interventional prospective includes 30 consecutive cancer patients with cachexia and refractory cachexia and their caregivers, assisted by the Specialised Palliative Care Team. The recruitment will last 1 year. The intervention involves two components: (1) psychoeducational intervention: 3 weekly face-to-face consultations between dyads and trained nurses to help the dyads cope with involuntary weight loss and strengthening dyadic coping resources and (2) rehabilitation intervention: 3 biweekly educational sessions between dyads and trained physiotherapists focused on self-management, goal-setting, physical activity with three home exercise sessions per week.The primary endpoint will be in adherence to the intervention, indicated by a level of completion greater than or equal to 50% in both components. The secondary endpoints will be QoL (Functional Assessment of Anorexia-Cachexia Therapy), caregiver burden (Zarit Burden), physical performance (Hand-Grip strength and 30 seconds sit-to-stand test), and the acceptability of the intervention (ad hoc semi-structured interviews with the dyads and the healthcare professionals). ETHICS AND DISSEMINATION: The study was approved by the Ethics Committee Area Vasta Emilia Nord, Azienda USL-IRCSS Reggio Emilia, Italy, number: 73/2019/SPER/IRCCSRE. The authors will provide the dissemination of the results through publication in international scientific journals. TRIAL REGISTRATION NUMBER: NCT04153019.

Meanings Emerging From Dignity Therapy Among Cancer Patients.

CONTEXT: Generativity is a process whereby patients nearing the end of life invest in those they will soon leave behind. In recent years, the trajectory of cancer has changed, as new therapies have prolonged survival and patients often live with metastatic disease for several years. For these patients and for the healthcare professionals who care for them it can be useful to understand if the concept of generativity is clinically salient. OBJECTIVES: To explore the meanings emerging from two dignity therapy questions, particularly salient to generativity, amongst cancer patients in different care settings. METHODS: We conducted a multicenter, retrospective, qualitative study in 1) home palliative care (life expectancy < 3 months); 2) specialized palliative care provided by team within an oncology hospital (life expectancy > 9-12 months); and 3) oncological day hospital (potentially curable disease). We thematically analyzed the answers of two dignity therapy questions. RESULTS: Three themes and related meanings emerged from 37 dignity therapy sessions with respect to the two questions: 1) Meanings concerning the present life and illness, including the experience of suffering; 2) Thoughts and actions towards the self, including ways in which the patients have felt alive; 3) Thoughts and actions towards significant others, especially values that are based mainly on love for oneself and for others. No notable differences across stages and care settings emerged in terms of the meanings emerging from two dignity therapy questions. CONCLUSION: Conversations about generativity could inform clinicians on how to communicate about existential and meaning-based issues across different stages of illness.

Construction of new personal meanings by cancer patients: a qualitative analysis in an Italian patient population.

PURPOSE: The goal of this study is to investigate the meaning that cancer patients in active therapy and/or rehabilitation give to their illness and resources they rely on to build new experiences of meaning and a future perspective. METHODS: The present study consisted in a summative content analysis of answers to open questions of the Purpose In Life (PIL) Questionnaire administered to 158 consecutive patients with non-advanced cancer (no metastases). The PIL is an attitude scale that indicates the degree of attainment of meaning and purpose in life and is divided into three sections: a first 20-item quantitative section, with statements rated on a 7-point verbal scale with two anchoring phrases (part A); a qualitative section with 13 open-end items and paragraph composition section addressing the future goals (part B) and past meaningful experience (part C). For the present study, we analyzed the answers to open questions, most interesting in a therapeutic contest related to the meanings associated with life, illness, and suffering to understand the experienced of the cancer patients. RESULTS: The main recurring themes in PIL section B analyzed associated to the sense of life, disease, and death are as follows: meaning (positive/negative), personal dimension, religiousness; physical health, family, normal life; negative sense of death, the end, natural transition, religious belief, consolation, mystery, rejection; opportunity, negativity. Whereas main themes emerging from section C were associated to life goals of the interviewed patients: the desire of realization in the future perspective; the value of life; physical health and healing; guiding values; plus three more themes, distinguishable, but with a minor recurrence: legacy responsibility, religiousness, lack of purpose/resignation. CONCLUSION: The use of summative content analysis evidenced the recurrence of a strong sense of positivity, present in the majority of the interviews. In particular, this positivity is shown by the use of words associated frequently to self-consciousness and self-evaluation, desire of happiness, and desire of contributing to the good of significant others and of taking care of your own life in order to give a positive contribution.

Sexual satisfaction assessment in 194 nonmetastatic cancer patients on treatment or in follow-up.

AIMS AND BACKGROUND: Sexuality is an important aspect of quality of life, but health care professionals still avoid discussing sexual issues with cancer patients. METHODS AND STUDY DESIGN: We present a secondary analysis of sexuality issues according to the results of a survey on 266 patients with early-stage cancer. The aim of the survey was to ascertain the feasibility and clinical usefulness of questionnaires (Patient Dignity Inventory, PDI; Hospital Anxiety and Depression Scale, HADS; Edmonton Symptom Assesssment Scale, ESAS; FACIT-spiritual well-being scale, FACIT-SP; System of Belief Inventory, SBI-15R) investigating aspects such as dignity, hope and research of meaning in life. The present study is an ancillary analysis of the full sample, and we have focused on the results of FACIT-SP about the correlation between sexual satisfaction and clinical characteristics in 108 patients having solid tumors and 86 having hematological malignancies with no metastases who were on active cancer treatment or in follow-up in four different cancer treatment settings during the first half of 2011. RESULTS: The median age of the 194 patients was 65 years, 112 were women, 155 were undergoing treatment and 39 were in follow-up. Eighty-three patients were above the cutoff score for HADS. Among the 171 believers, 80 were churchgoers and 91 were nonchurchgoers, whereas the nonbelievers among the patients were 23. Thirty-five percent of the patients did not respond to the sexuality item of the questionnaire. Among the responders (n = 126), 36% reported having no sexual satisfaction (score = 0). Sexual dissatisfaction was greater in older patients (47% vs 31%, not significant [NS]), women (43% vs 27%, NS), patients on treatment (38% vs 25%, NS), patients who requested psychological support (53% vs 25%, P = 0.001), patients with high levels of anxiety and depression, i.e., HADS scores >10 (44% vs 30%, NS), nonbelievers (61% vs 34% among churchgoers, 29% among believers but nonchurchgoers, P = 0.046). CONCLUSIONS: One out of 3 patients did not respond to the item on sexuality. Among the responders, 1 out of 3 reported having no sexual satisfaction. Half of the patients receiving psychological support considered their sexual life not satisfying. Clinical interviews and specific questionnaires on sexuality should be used to investigate this particular aspect.

The Edmonton Symptom Assessment System (ESAS) as a screening tool for depression and anxiety in non-advanced patients with solid or haematological malignancies on cure or follow-up.

BACKGROUND: Symptoms' assessment should be considered a clinical practice routine in all cancer stages. The Edmonton Symptom Assessment System (ESAS) is a ten-item patient-rated symptom assessment developed and validated for population affected by cancer in different languages and cultures. The main objective of this study was to assess the performance of ESAS items on anxiety and depression when detecting Hospital Anxiety Depression Scale (HADS) 'cases'. METHODS: A cross-sectional study was carried out on 194 non-advanced patients with solid (108) or hematologic malignancies on cure or follow up, Karnofsky Performance Status ≥ 70, life expectancy > 6 months and no metastases. Patients were assessed by means of ESAS and by HADS. Receiving operator characteristic (ROC) analysis of ESAS anxiety and depression items versus cases of severe (cutoff 11) anxiety and depression according to HADS-specific subscales was performed. RESULTS: Depression and anxiety ESAS items correlated strongly (0.707, Spearman). Area under the curve ranged between 0.84 and 0.96 for the two ESAS items when detecting severe anxiety or depression HADS cases (cutoff = 11). ESAS anxiety or depression scores >3 detected quite well the severe depression HADS cases (Sensibility = 75-Specificity = 84, Sensibility = 87-Specificity = 90, respectively). CONCLUSIONS: Anxiety or depression ESAS items score >3 can be applied as a useful, easy and not time consuming screening tool for assessing anxiety and depression in non-advanced patients with solid or haematological malignancies.

Patient dignity inventory (PDI) questionnaire: the validation study in Italian patients with solid and hematological cancers on active oncological treatments.

BACKGROUNDS: In Oncology, little is known about dignity-related distress and the issues that influence the sense of dignity for patients. We validated the Patient Dignity Inventory (PDI) questionnaire in Italian patients on oncological active treatments. METHODS: After the translation procedures, the PDI was administered to 266 patients along with other questionnaires to assess the psychometric properties of the Italian version of PDI. Factor structure was tested by both explorative and confirmatory factor analyses. Concurrent validity was tested through convergent and divergent validity with validated questionnaires inquiring about physical and psychological symptoms, and religiosity. The test/retest reliability was assessed through the concordance coefficient of Linn (two-week interval, 80 patients). RESULTS: The explorative analysis suggested one factor only loading highly on all the 25 items (>.45) and explaining the 48% variance; confirmative analysis and Cronbach alpha (0.96) confirmed the adequacy of the one-factor model. In the 2-week test-retest study, a concordance coefficient of 0.73 (95% CI, 0.64-0.83) was found. High correlations of problems with dignity were found with both physical and psychological symptoms (0.52 and 0.64 rho coefficient, respectively), and a moderate inverse correlation with spiritual well being (-.40). The dignity construct, as measured by PDI, proved to be orthogonal to that of religiosity (-.02). CONCLUSIONS: The Italian version of PDI is a valid and reliable tool to evaluate the dignity related-distress in out-patients with solid and hematological cancers, on active oncological treatments, in non advanced stages of the disease.

Hope Herth Index (HHI): a validation study in Italian patients with solid and hematological malignancies on active cancer treatment.

AIMS AND BACKGROUND: Although hope is a widely used term, the experience of hope in patients with chronic or even life-threatening diseases is often disregarded due to the scarcity of carefully designed and validated assessment tools. The aim of this study was to validate the Hope Herth Index (HHI) questionnaire in the Italian population of patients with solid or hematological malignancies during active cancer treatment. METHODS: After the translation procedures, the psychometric properties of the Italian version of HHI were evaluated in 266 patients with non-advanced cancer cared for in four different settings. Summative scores ranged from 12-48, with a higher score denoting greater hope. Confirmative factorial analysis was performed to assess dimensionality. The test-retest reliability was assessed by means of the Lin concordance coefficient (two weeks' interval, 80 patients). Concurrent validity was assessed through the following questionnaires: Hospital Anxiety and Depression Scale (HADS), Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp), Edmonton Symptom Assessment Scale (ESAS), and System Belief Inventory (SBI-15R). RESULTS: A total of 266 patients were enrolled. Confirmative factor analysis did not confirm the original three-factor solution, whereas a one-factor solution did perform well. Cronbach's alpha was 0.84 and the test-retest reliability was 0.64 (95% CI 0.51; 0.76). Large convergence was found with spiritual well-being as measured by the FACIT-Sp (0.69) and with anxiety-depression as measured by the HADS (inverse correlation: -0.51). Physical symptoms and religiousness were only slightly correlated, as expected. CONCLUSIONS: The Italian version of HHI is a valid and reliable assessment tool - useful to initiate conversation with someone who is troubled but finds it difficult to talk - in patients with either solid or hematological malignancies on active cancer treatment during the non-advanced stages of the disease.