Living in the face of death: Studies on palliative care in upper GI cancer patients

This thesis explores palliative care provided to patients with advanced upper gastrointestinal (GI) cancer. The 5-year survival rates for these cancer sites range between 4 and 17%, which implies that many of these patients require palliative care. Considering the fact that there is no uniform management policy aiming at improvement of quality of life (QoL) of these patients and their families, we decided to study different interventions with effect on this primary aim. The introduction, CHAPTER 1, provides background information on the main subjects of the thesis, i.e., patients with advanced upper GI cancer, the concept of quality of life, and our questions that stand at the basic of it. The transition from care with curative intent to palliative care marks a drastic change in the life-expectancy of a patient, and thus drastically and negatively affects patient’s view of the future. The patient has to adjust to this new situation. In CHAPTER 2 we present the results of a pilot-study on feasibility and utility of the provision of CD recordings on consultations involving the transition to palliative care for 17 patients with irresectable or recurrent esophageal or head or neck cancer. We found no major technical and procedural problems related to the provision of these recordings and the recordings were well-received and listening by most of our patients and their family. After 1 month we found a trend towards a poorer quality of life but an improved openness to discuss cancer-related issues, in the CD group. Knowledge of symptom prevalence and intensity, and health care needs of patients with non-curable GI cancer is important in clinical practice as it enables professional caregivers to focus on these issues and achieve optimal symptom control of patients. CHAPTER 3 presents the specific problems and needs of 57 patients with advanced upper GI cancer, found in a cross sectional study. They experienced multiple, multidimensional problems, in particular physical and emotional problems. Most patients expressed a need for professional care for these, this was however not the case for LOA problems that are also frequently experienced as problematic. Inadequate care was received for fatigue, need for written information, fear of physical suffering, the assurance that hospitalization is possible when necessary, and frustration because of the inability to do as much as before. For patients with esophageal cancer as well as for patients with cancer of the periampullary area (head of the pancreas, distal bile duct, papilla of Vater), and with distal stomach or duodenal cancer, dysphagia is known as a common symptom, causing significant distress. Self-expandable metal stents are commonly used for the palliation of malignant obstruction because of inoperable disease. In CHAPTER 4 the findings of 3 studies on new developed stents are presented, with focus on both safety and efficacy. We found that the Ella and Alimaxx stent were no alternative to the current, conventional stents for the palliation of dysphagia, while the Wallflex enteral stent was a good alternative for enteral obstruction. The Ella stent had an unacceptably high rate of migration (16 times in 45 patients) and the Alimaxx stent a high complication rate (18 times in 44 patients), particularly hemorrhage. The poor prognosis of upper GI cancer combined with the multidimensional problems and re-interventions for esophageal, biliary or enteral obstruction that arise in this short period suggested a need for close monitoring and support, instead of the conventional 1-2 monthly hospital follow-up at the outpatient clinic. In CHAPTER 5 is a new strategy for follow-up for advanced upper GI cancer patients, i.e., nurse-led follow-up by home visits (n=36) compared with the usual medical follow up in outpatient clinic (n=30), in a randomized study. On the basis of the main problems experienced by these patients (chapter 3), we developed guidelines for nurse-led follow-up. Patients who received nurse-led follow-up at home were more satisfied with their visits, whereas their quality of life and healthcare consumption within the first four months remained the same. Nurse-led follow-up was per visit less costly than the conventional follow-up by the physician. However, the total costs for the four months follow-up in this study were higher due to a higher frequency of visits in this group. In CHAPTER 6, the main results of the thesis are summarized, followed by a reflection on the methodology, the general conclusions concerning the main objectives of the thesis and implications for further research and practice. We recommended the use of CD recordings, Wallflex enteral stent and another strategy of follow-up instead of the conventional in a new policy for advanced upper GI cancer patients of the hospital. The first recommendation had to be studied more in-depth and in a study with a larger sample size. The last recommendation had to be studied further also, preferable in a costs utility study and with the comparison of new strategy such as tele-health.