Supportive and Palliative Care

Multimorbidity in older adults living with and beyond cancer Purpose of review The current review draws attention to the need for longer term management of multiple conditions in older adults with cancer. Recent findings Older people living with and beyond cancer are more likely than younger people to have higher prevalence of multimorbidity leading to an overall increase in illness and treatment burdens, limiting health-related quality of life (QoL), and capacity to self-manage. Older age presents a higher risk of cancer treatment side-effects and development or progression of other conditions, leading to worsening health, long-lasting functional problems, and social isolation. Although many prioritize functional independence and continuance of valued activities over survival, older people living with multimorbidity are more likely to experience poor physical functioning during and beyond cancer treatment. Summary Cancer treatment decisions and survivorship plans should be developed in the context of other conditions and in line with the individual's priorities for continued QoL. More research is needed to guide service development and clinical practice in this important area. Correspondence to Dr Teresa Corbett, School of Health Sciences, University of Southampton, Building 67 Room 3031, Highfield, Southampton SO17 1BJ, UK. Tel: +44 2380598292; e-mail: t.k.corbett@soton.ac.uk Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Caring for the informal cancer caregiver Purpose of review Informal cancer caregivers play a vital role in the physical, functional, and emotional well being of cancer patients. However, the majority of informal caregivers are not prepared for their caregiving role. We reviewed and synthesized the recent literature (last 18 months) and focused on research in the following understudied areas: technology-driven interventions for informal caregivers; informal caregivers of older adults with cancer; interrelationship between informal caregiver and dyadic outcomes; and research priorities and guidelines to improve informal caregiver support. Recent findings Studies focused on technology-driven informal caregiver interventions, with evidence of good feasibility and acceptability with benefits for burden and quality of life (QOL). Studies also focused on QOL for caregivers of older adults with cancer. Finally, research priorities and clinical guidelines were established through Delphi survey studies. Summary Despite the substantial evidence on informal cancer caregiving, more research is needed to further characterize caregivers at high risk for burden, explicate interrelationships between caregiver/patient outcomes, and test innovative and scalable interventions. Studies are also needed to understand the specific needs of informal caregivers in cancer surgery, an understudied treatment population. Correspondence to Virginia Sun, PhD, RN, Associate Professor, Division of Nursing Research and Education, Department of Population Sciences, City of Hope, 1500 East Duarte Road, Duarte, CA 91010, USA. Tel: +1 626/218 3122; e-mail: vsun@coh.org Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Complexity when living with cancer No abstract available

Ketamine and lidocaine infusions decrease opioid consumption during vaso-occlusive crisis in adolescents with sickle cell disease Purpose of review Recurrent exposure to opioids can lead to development of opioid tolerance and opioid-induced hyperalgesia through activation of N-methyl-D-aspartate receptors. N-methyl-D-aspartate receptor antagonists ketamine and lidocaine can modulate development of opioid tolerance and OIH. This study evaluated the utility of ketamine and/or lidocaine in decreasing opioid consumption during acute pain episodes in adolescents with sickle cell disease. There has been an increased effort to promote opioid-sparing pain relieving methods given the ongoing opioid epidemic. Recent findings There have been six studies published over the past decade that highlight the ability of ketamine to reduce opioid consumption in the management of sickle cell disease-related pain, primarily in adult patients. There has been one study (2015) that demonstrated a similar benefit with lidocaine, however this was also in adult patients. Summary We retrospectively evaluated treatment with ketamine and/or lidocaine infusions in adolescents hospitalized for vaso-occlusive crisis (VOC). Patients served as self-controls using a comparison with a previous control admission for VOC. The use of ketamine and/or lidocaine as adjuncts to opioids resulted in lower daily opioid consumption in three of four patients. Our study suggests that ketamine and/or lidocaine infusions may be useful adjuncts in reducing opioid exposure during VOC pain. Correspondence to Doralina L. Anghelescu, MD, Department of Pediatric Medicine, Division of Anesthesiology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Mail Stop 130, Memphis, TN 38105, USA. Tel: +1 901 595 4032; fax: +1 901 595 4061; e-mail: doralina.anghelescu@stjude.org Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Interdisciplinary management of chronic breathlessness Purpose of review Breathlessness is a common yet complex symptom of advanced disease. Effective management will most likely draw upon the skills of multiple disciplines and professions. This review considers recent advances in the management of chronic breathlessness with regards to interdisciplinary working. Recent findings There are growing data on interventions for chronic breathlessness that incorporate psychosocial mechanisms of action, for example, active mind–body treatments; and holistic breathlessness services that exemplify interprofessional working with professionals sharing skills and practice for user benefit. Patients value the personalized, empathetic and understanding tenor of care provided by breathlessness services, above the profession that delivers any intervention. Workforce training, decision support tools and self-management interventions may provide methods to scale-up these services and improve reach, though testing around the clinical effects of these approaches is required. Summary Chronic breathlessness provides an ideal context within which to realize the benefits of interdisciplinary working. Holistic breathlessness services can commit to a comprehensive approach to initial assessment, as they can subsequently deliver a wide range of interventions suited to needs as they are identified. Correspondence to Dr Matthew Maddocks, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, Bessemer road, London SE5 9PJ, UK. Tel: +44 202 7848 5252; e-mail: matthew.maddocks@kcl.ac.uk Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Multidimensional measurement of breathlessness: recent advances Purpose of review Breathlessness is a multidimensional sensation for which a range of instruments exists for children, youth and adults, capable or unable to self-report distress with breathing. This review presents developments and applications of multidimensional assessments of breathlessness. Recent findings Excluding unidimensional measures and instruments assessing the impact of breathlessness, at least eight psychometrically robust instruments exist, which comprehensively assess one or more specific domains of the sensation of breathlessness (intensity, sensory quality, affective distress). These instruments have evolved from modest beginnings (describing breathlessness in various patient cohorts) to a growing use as primary or secondary outcomes in observational, clinical, and experimental trials exploring breathlessness mechanisms and intervention effects. For adults and children unable to consciously communicate breathing discomfort, instruments include combinations of physiological and behavioural markers of distress. Nonverbal (graphic scales) have potential use beyond paediatric applications. Summary Traditionally, breathlessness has been considered as a 'black box' with unidimensional measures reflecting box size (intensity, unpleasantness). Multidimensional instruments reveal the composition of the black box of breathlessness allowing detailed descriptions of an individual's breathlessness experience, quantification of sensory qualities, affective distress, and emotional responses with the potential to capture change over time and treatment effects in each dimension. Correspondence to Dr Marie T. Williams, Alliance for Research in Exercise, Nutrition and Activity (ARENA), School of Health Sciences, University of South Australia, North Terrace, Adelaide, SA 5000, South Australia, Australia. Tel: +61 8 8302 1153; fax: +61 8 830 22853; e-mail: Marie.williams@unisa.edu.au Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Supplemental oxygen for the management of dyspnea in interstitial lung disease Purpose of review This article presents a summary of the evidence relating to supplemental oxygen use for the management of dyspnea in patients with interstitial lung disease (ILD). Recent findings In contrast to the majority of the available literature, recent findings suggest that supplemental oxygen can significantly reduce exertional dyspnea in ILD. ILD patients' need for supplemental oxygen often surpasses the levels that the most commonly used oxygen delivery systems provide. More effective delivery of supplemental oxygen has the potential for greater relief of dyspnea. There is also evidence suggesting that indications for supplemental oxygen may differ in ILD compared with other chronic lung diseases. Summary Large clinical trials are needed to determine if the reductions in dyspnea with supplemental oxygen observed in the laboratory setting can translate into meaningful benefits in everyday life for patients with ILD. More effective and practical oxygen delivery systems are needed. Future guidelines should consider including recommendations addressing the potential role of supplemental oxygen for mildly hypoxemic patients with ILD as well as recommendations specific to supplemental oxygen use for exercise training in ILD. Correspondence to Michele R. Schaeffer, PhD, Centre for Heart Lung Innovation, Providence Healthcare Research Institute, The University of British Columbia, St. Paul's Hospital, 166-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. Tel: +1 604 806 8835; e-mail: michele.schaeffer@hli.ubc.ca Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Treating advanced penile cancer: where do we stand in 2019? Purpose of review Penile squamous cell carcinoma (PSCC) remains a challenging malignancy to treat and there is an urgent need of significant improvements at all levels of medical care. In the current review, we summarized the significant obstacles encountered during management of PSCC and discussed the clinical relevance of novel findings and their potential to address these obstacles. Recent findings The recent genetic and immunological advances suggest that patients with PSCC can benefit from available targeted therapy and immunotherapy options. Moreover, evidence has accumulated over time suggesting that majority of the patients diagnosed with PSCC suffer from psychosocial problems and impaired rehabilitation. Summary Effective prevention strategies against PSCC are urgently needed especially in developing countries given the limited therapeutic options. About a quarter of patients with metastatic PSCC appear to benefit from available targeted therapies and about half of the patients can be a suitable candidate for immune checkpoint blockade as half of the PSCC cases exhibit PD-L1 expression. Moreover, increased public awareness, healthcare provider education and social support programs may help patients suffering from PSCC coping with the psychosocial burdens of the disease. Correspondence to Philippe E. Spiess, MD, MS, FRCS(C), FACS, Senior Member, Department of GU Oncology, Senior Member, Department of Tumor Biology, Department of Genitourinary Oncology, Assistant Chief of Surgical Services, Moffitt Cancer Center, Professor, Department of Urology, University of South Florida, FL 33612, USA. Tel: +1 813 745 2484; fax: +1 813 745 8494; e-mail: philippe.spiess@moffitt.org Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Cytoreductive nephrectomy in metastatic kidney cancer: what do we do now? Purpose of review Metastatic renal cell carcinoma (mRCC) has traditionally been treated with a combination of targeted systemic therapy and cytoreductive nephrectomy. This approach has recently become a topic of debate, because of new randomized data suggesting a lack of survival benefit for cytoreductive nephrectomy. We review the literature relevant to cytoreductive nephrectomy in the modern era of targeted and immune systemic therapy, and discuss the ongoing role of surgery for treatment of patients with mRCC. Recent findings Randomized trials in the cytokine era of systemic therapy for mRCC demonstrated a survival benefit to cytoreductive nephrectomy, which led to its widespread adoption. There is overwhelming support in favor of cytoreductive nephrectomy from large studies using retrospective data in the targeted therapy era. A recent randomized control trial (CARMENA) failed to show superiority of cytoreductive nephrectomy in combination with sunitinib, versus sunitinib alone with respect to overall survival. The trial had major limitations including selection of many poor-risk patients, which we know do not benefit from surgery. The results of CARMENA should lead to the abandonment of cytoreductive nephrectomy in poor-risk and many intermediate-risk patients with mRCC. However, there is a knowledge gap with respect to the role of cytoreductive nephrectomy in patients with good risk disease, and we argue that these patients should be strongly considered for cytoreductive nephrectomy. Summary Cytoreductive nephrectomy continues to play an important role in the multidisciplinary management of mRCC; however, diligent patient selection is crucial, as only patients with good risk features are likely to derive benefit from surgery. Correspondence to Ricardo A. Rendon, Department of Urology, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Room 210, 5-South, Victoria Building, 1276 South Park St, Halifax, NS, Canada B3H 2Y9. Tel: +1 902 473 6604; fax: +1 902 492 2437; e-mail: rrendon@dal.ca Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Treating the primary in metastatic prostate cancer: where do we stand? Purpose of review Traditionally, local treatment was reserved for palliative control of symptoms in men with metastatic prostate cancer. In the past few years there have been many advances in the systemic options available. The aim of this review is to explore the evidence in support of treating the primary tumor despite the presence of metastatic disease. Recent findings There is a wealth of retrospective studies demonstrating advantages of local treatment [radical prostatectomy or radiation therapy (RT)] in metastatic disease. As these studies are prone to bias, treatment of the primary in the metastatic setting has not been adopted. However, two recent prospective randomized trials (HORRAD and STAMPEDE) have addressed the role of RT to the prostate in metastatic disease. The STAMPEDE sub-group analysis of low-volume metastatic disease demonstrated a survival advantage in favor of the RT arm (hazard ratio 0.68; 95% CI 0.52–0.90). The HORRAD trial showed a similar but nonsignificant trend towards RT (hazard ratio 0.68; 95% CI 0.42–1.10). As a result, the 2019 European Association of Urology and National Comprehensive Cancer Network guidelines now include RT to the prostate as an option in the setting of low-volume metastatic disease. Summary Although systemic treatment remains standard of care for men with metastatic prostate cancer, there is recent compelling evidence from two prospective randomized trials supporting treatment of the prostate in oligometastatic disease. Correspondence to Robert J. Hamilton, MD, MPH, FRCSC, Staff Urologist, Associate Professor, Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, 600 University Avenue, Toronto, ON, Canada M5G 1X5. Tel: +1 416 946 2909; fax: +1 416 946 6590; e-mail: rob.hamilton@uhn.ca Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Alexandros Sfakianakis
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