Daily Archives: September 26, 2024
RCT: Telehealth-Delivered Early Palliative Care Equivalent to In-Person Care in Advanced Lung Cancer
26 Sep, 2024 | 15:06h | UTCBackground: Patients with advanced lung cancer often face a high symptom burden and decreased quality of life (QOL), but access to early palliative care, which can improve these outcomes, remains limited. While telehealth has become increasingly utilized due to the COVID-19 pandemic, it is unclear whether virtual palliative care is as effective as in-person care.
Objective: To compare the effect of early palliative care delivered via secure video vs in-person visits on the quality of life of patients with advanced non–small cell lung cancer (NSCLC).
Methods: This multisite, randomized comparative effectiveness trial enrolled 1250 adults with advanced NSCLC from 22 cancer centers in the US between June 2018 and May 2023. Participants were randomized to receive either early palliative care via video visits or in person every four weeks. The primary outcome was QOL measured by the Functional Assessment of Cancer Therapy-Lung (FACT-L) questionnaire at 24 weeks. Secondary outcomes included caregiver participation in palliative care visits and patient and caregiver satisfaction with care, mood symptoms, coping, and prognostic understanding.
Results: By week 24, patients in both groups reported equivalent QOL scores, with the video visit group scoring a mean of 99.7 compared to 97.7 in the in-person group (difference of 2.0 points, 90% CI, 0.1-3.9; P = .04 for equivalence). Both groups experienced similar improvements in QOL from baseline (mean increase of 8.4 points for video visits and 6.9 points for in-person care). Caregiver participation in palliative care visits was lower in the video visit group (36.6% vs 49.7%; P < .001). No significant differences were found between the groups in caregiver QOL, patient or caregiver satisfaction with care, mood symptoms, or coping strategies.
Conclusions: Early palliative care delivered via telehealth was equivalent to in-person visits in improving QOL for patients with advanced NSCLC. This underscores the potential of telehealth to increase access to essential palliative care services for this population without compromising care quality.
Implications for Practice: Telehealth can provide a feasible alternative to in-person palliative care, especially for patients with advanced lung cancer who face barriers to in-person visits, such as transportation challenges. However, strategies to enhance caregiver involvement in virtual visits may need to be developed.
Study Strengths and Limitations: Strengths include the large, multisite randomized design and the use of validated outcome measures. Limitations involve the COVID-19 pandemic’s impact, which caused some intervention contamination due to unavoidable video visits in the in-person group. Additionally, caregiver participation was lower than expected, potentially limiting the generalizability of results regarding caregiver outcomes.
Future Research: Further studies should explore the long-term impact of telehealth on palliative care outcomes and investigate ways to enhance caregiver involvement in virtual care.
RCT: MRI-Guided Biopsy Reduces Overdiagnosis of Clinically Insignificant Prostate Cancer
26 Sep, 2024 | 12:22h | UTCBackground: Overdiagnosis of clinically insignificant prostate cancer is a significant issue in population-based screening programs, primarily when prostate-specific antigen (PSA) testing is followed by systematic biopsy. Magnetic resonance imaging (MRI)-guided biopsies, which avoid systematic biopsies in men with negative MRI results, have shown potential in reducing unnecessary cancer diagnoses. However, long-term data are needed to confirm the safety and efficacy of this approach.
Objective: To evaluate whether MRI-targeted biopsies, when combined with PSA screening, can reduce the detection of clinically insignificant prostate cancer without compromising the identification of clinically significant or advanced disease.
Methods: This population-based, randomized trial in Sweden (GÖTEBORG-2) enrolled 13,153 men aged 50-60 years who underwent PSA screening. Men with PSA levels ≥3 ng/mL were randomized into two groups: (1) MRI-targeted biopsy only in cases with suspicious lesions, or (2) systematic biopsy in all cases with PSA elevation. Screening occurred every 2, 4, or 8 years depending on PSA levels, with follow-up for up to four years. The primary outcome was the detection of clinically insignificant prostate cancer, and secondary outcomes included clinically significant and advanced or high-risk prostate cancer.
Results: After a median follow-up of 3.9 years, the detection of clinically insignificant prostate cancer was significantly lower in the MRI-targeted biopsy group (2.8%) compared to the systematic biopsy group (4.5%), with a relative risk (RR) of 0.43 (95% CI, 0.32-0.57; P < 0.001). The relative risk of detecting clinically significant cancer was 0.84 (95% CI, 0.66-1.07), indicating no significant difference between the two groups. Advanced or high-risk cancers were detected in 15 men in the MRI group and 23 men in the systematic group (RR, 0.65; 95% CI, 0.34-1.24). Severe adverse events occurred in five patients (three in the systematic biopsy group, two in the MRI-targeted biopsy group).
Conclusions: Omitting biopsies in men with negative MRI results substantially reduced the diagnosis of clinically insignificant prostate cancer without increasing the risk of missing clinically significant or advanced cancers. MRI-targeted biopsy strategies can effectively limit overdiagnosis while maintaining safety in screening programs.
Implications for Practice: MRI-targeted biopsies offer a promising strategy to reduce unnecessary cancer diagnoses and avoid overtreatment in prostate cancer screening. Clinicians should consider integrating MRI into prostate cancer screening algorithms, especially in cases with elevated PSA but no MRI-detected lesions. This approach may also decrease biopsy-related complications and patient anxiety.
Study Strengths and Limitations: Strengths of this trial include its population-based design, large sample size, and thorough follow-up. Limitations include its single-center setting in Sweden, which may limit generalizability to more diverse populations, and a modest participation rate of 50%.
Future Research: Further studies should assess the cost-effectiveness of widespread MRI use in prostate cancer screening and explore its utility in diverse populations. Investigations into novel biomarkers that could further refine patient selection for MRI-targeted biopsy are also warranted.