Key clinical point: A review of 58 YouTube videos on removal of long-acting reversible contraception showed more than 4 million views overall; reasons for removal included negative side effects, fear of side effects, and desire for pregnancy.

Major finding:  Most of the women who created the 58 videos were white (53%), 31% were Black, and 14% were Latina. Of these, 56 of 58 successfully removed their device and described the experience as positive in terms of ease of removal.

Study details: The data come from a review of 58 videos on self-removal of long-acting reversible contraception based on YouTube keyword searches. The videos included 48 individuals removing an intrauterine device and 10 removing an implant.

Disclosures: The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and by the National Science Foundation Graduate Research Fellowship Program. The researchers had no financial conflicts to disclose.

Source: Broussard K and Becker A. Contraception. 2021 Aug 13. doi: 10.1016/j.contraception.2021.08.002.

Key clinical point: A review of 58 YouTube videos on removal of long-acting reversible contraception showed more than 4 million views overall; reasons for removal included negative side effects, fear of side effects, and desire for pregnancy.

Major finding:  Most of the women who created the 58 videos were white (53%), 31% were Black, and 14% were Latina. Of these, 56 of 58 successfully removed their device and described the experience as positive in terms of ease of removal.

Study details: The data come from a review of 58 videos on self-removal of long-acting reversible contraception based on YouTube keyword searches. The videos included 48 individuals removing an intrauterine device and 10 removing an implant.

Disclosures: The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and by the National Science Foundation Graduate Research Fellowship Program. The researchers had no financial conflicts to disclose.

Source: Broussard K and Becker A. Contraception. 2021 Aug 13. doi: 10.1016/j.contraception.2021.08.002.

Key clinical point: A review of 58 YouTube videos on removal of long-acting reversible contraception showed more than 4 million views overall; reasons for removal included negative side effects, fear of side effects, and desire for pregnancy.

Major finding:  Most of the women who created the 58 videos were white (53%), 31% were Black, and 14% were Latina. Of these, 56 of 58 successfully removed their device and described the experience as positive in terms of ease of removal.

Study details: The data come from a review of 58 videos on self-removal of long-acting reversible contraception based on YouTube keyword searches. The videos included 48 individuals removing an intrauterine device and 10 removing an implant.

Disclosures: The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and by the National Science Foundation Graduate Research Fellowship Program. The researchers had no financial conflicts to disclose.

Source: Broussard K and Becker A. Contraception. 2021 Aug 13. doi: 10.1016/j.contraception.2021.08.002.

Key clinical point: Among young women, the average Pregnancy Risk Index (PRI) was 4.75; individuals using teratogenic medication had the lowest PRI (0.32); 88% of these individuals used reversible contraception and 31% used long-acting reversible contraception.

Major finding:  Approximately 73% of sexually active young women received contraceptive counseling, which was associated with a significantly increased use of reversible and dual contraception, but not long-acting reversible contraception. At last reported vaginal sex, 65% reported using condoms, 49% reported using reversible contraception, and 12% reported using long-acting reversible contraception.

Study details: The data come from a cross-sectional survey of 177 hospitalized females aged 14 to 21 years at two academic medical centers; the surveys assessed sexual health behaviors, contraceptive use, contraceptive counseling, and pregnancy complications. Researchers calculated the Pregnancy Risk Index (the number per 100 individuals who will become pregnant in the next year).

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Hunt JA et al. Hosp Pediatr. 2021 Sep 13. doi: 10.1542/hpeds.2021-005810.

Key clinical point: Among young women, the average Pregnancy Risk Index (PRI) was 4.75; individuals using teratogenic medication had the lowest PRI (0.32); 88% of these individuals used reversible contraception and 31% used long-acting reversible contraception.

Major finding:  Approximately 73% of sexually active young women received contraceptive counseling, which was associated with a significantly increased use of reversible and dual contraception, but not long-acting reversible contraception. At last reported vaginal sex, 65% reported using condoms, 49% reported using reversible contraception, and 12% reported using long-acting reversible contraception.

Study details: The data come from a cross-sectional survey of 177 hospitalized females aged 14 to 21 years at two academic medical centers; the surveys assessed sexual health behaviors, contraceptive use, contraceptive counseling, and pregnancy complications. Researchers calculated the Pregnancy Risk Index (the number per 100 individuals who will become pregnant in the next year).

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Hunt JA et al. Hosp Pediatr. 2021 Sep 13. doi: 10.1542/hpeds.2021-005810.

Key clinical point: Among young women, the average Pregnancy Risk Index (PRI) was 4.75; individuals using teratogenic medication had the lowest PRI (0.32); 88% of these individuals used reversible contraception and 31% used long-acting reversible contraception.

Major finding:  Approximately 73% of sexually active young women received contraceptive counseling, which was associated with a significantly increased use of reversible and dual contraception, but not long-acting reversible contraception. At last reported vaginal sex, 65% reported using condoms, 49% reported using reversible contraception, and 12% reported using long-acting reversible contraception.

Study details: The data come from a cross-sectional survey of 177 hospitalized females aged 14 to 21 years at two academic medical centers; the surveys assessed sexual health behaviors, contraceptive use, contraceptive counseling, and pregnancy complications. Researchers calculated the Pregnancy Risk Index (the number per 100 individuals who will become pregnant in the next year).

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Hunt JA et al. Hosp Pediatr. 2021 Sep 13. doi: 10.1542/hpeds.2021-005810.

Key clinical point: Women with potential contraindications to estrogen were significantly more likely than those without contraindication to use permanent contraception or no contraception

Major finding:  A total of 15% of women with potential contraindications to estrogen reported using the pill, patch, or ring, compared to 20% of women with no potential contraindications to estrogen. Women with contraindications to estrogen also were significantly more likely than those without contraindications to use permanent contraception (odds ratio vs. patch, pill, or ring 1.48) or no contraception (OR vs. patch, pill, or ring 1.37). 

Study details: The data come from surveys of 32,098 women aged 18-44 years who participated in the 2017 Behavioral Risk Factor Surveillance System, 16% of whom had at least one potential contraindication to estrogen.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Erly SJ et al. J Womens Health. 2021 Sep 1. doi: 10.1089/jwh.2020.8905. 

Key clinical point: Women with potential contraindications to estrogen were significantly more likely than those without contraindication to use permanent contraception or no contraception

Major finding:  A total of 15% of women with potential contraindications to estrogen reported using the pill, patch, or ring, compared to 20% of women with no potential contraindications to estrogen. Women with contraindications to estrogen also were significantly more likely than those without contraindications to use permanent contraception (odds ratio vs. patch, pill, or ring 1.48) or no contraception (OR vs. patch, pill, or ring 1.37). 

Study details: The data come from surveys of 32,098 women aged 18-44 years who participated in the 2017 Behavioral Risk Factor Surveillance System, 16% of whom had at least one potential contraindication to estrogen.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Erly SJ et al. J Womens Health. 2021 Sep 1. doi: 10.1089/jwh.2020.8905. 

Key clinical point: Women with potential contraindications to estrogen were significantly more likely than those without contraindication to use permanent contraception or no contraception

Major finding:  A total of 15% of women with potential contraindications to estrogen reported using the pill, patch, or ring, compared to 20% of women with no potential contraindications to estrogen. Women with contraindications to estrogen also were significantly more likely than those without contraindications to use permanent contraception (odds ratio vs. patch, pill, or ring 1.48) or no contraception (OR vs. patch, pill, or ring 1.37). 

Study details: The data come from surveys of 32,098 women aged 18-44 years who participated in the 2017 Behavioral Risk Factor Surveillance System, 16% of whom had at least one potential contraindication to estrogen.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Erly SJ et al. J Womens Health. 2021 Sep 1. doi: 10.1089/jwh.2020.8905. 

Key clinical point: Expulsion rates were similar for women using a 52 mg levonorgestrel intrauterine system for heavy menstrual bleeding and those who used it for contraception; a history of cesarean delivery increased the risk of expulsion in both groups.

Major finding:  Expulsion of the device occurred in 548 of the women with heavy menstrual bleeding (5.6%) and 315 of the women using the device for contraception (5.6%). The odds ratio for expulsion for women with a history of cesarean delivery in either group was 1.93.

Study details: The data come from an audit of 548 women who used a 52 mg levonorgestrel intrauterine system to manage heavy menstrual bleeding and 5,655 who used it for contraception.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Furlan RM et al. Contraception. 2021 Sep 5. doi: 10.1016/j.contraception.2021.09.001.

Key clinical point: Expulsion rates were similar for women using a 52 mg levonorgestrel intrauterine system for heavy menstrual bleeding and those who used it for contraception; a history of cesarean delivery increased the risk of expulsion in both groups.

Major finding:  Expulsion of the device occurred in 548 of the women with heavy menstrual bleeding (5.6%) and 315 of the women using the device for contraception (5.6%). The odds ratio for expulsion for women with a history of cesarean delivery in either group was 1.93.

Study details: The data come from an audit of 548 women who used a 52 mg levonorgestrel intrauterine system to manage heavy menstrual bleeding and 5,655 who used it for contraception.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Furlan RM et al. Contraception. 2021 Sep 5. doi: 10.1016/j.contraception.2021.09.001.

Key clinical point: Expulsion rates were similar for women using a 52 mg levonorgestrel intrauterine system for heavy menstrual bleeding and those who used it for contraception; a history of cesarean delivery increased the risk of expulsion in both groups.

Major finding:  Expulsion of the device occurred in 548 of the women with heavy menstrual bleeding (5.6%) and 315 of the women using the device for contraception (5.6%). The odds ratio for expulsion for women with a history of cesarean delivery in either group was 1.93.

Study details: The data come from an audit of 548 women who used a 52 mg levonorgestrel intrauterine system to manage heavy menstrual bleeding and 5,655 who used it for contraception.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Furlan RM et al. Contraception. 2021 Sep 5. doi: 10.1016/j.contraception.2021.09.001.

Key clinical point: Daily use of 75 µg norgestrel was effective contraception for both breastfeeding and non-breastfeeding women

Major finding:  Overall failure rates for non-breastfeeding women using 75 µg/day norgestrel ranged from 0-2.4/100 woman-years for an aggregate Pearl Index of 2.2. Among breastfeeding women, the 12-month life table cumulative pregnancy rates for norgestrel ranged from 0-3.4.

Study details: The data come from 13 studies of women who used a progestogen-only pill containing 75 µg/day norgestrel. The review included 6 studies with data on 3,144 women who were not breastfeeding and 7 studies with data on 5,258 women who were breastfeeding during part of the follow-up period. The women were followed for a total of 35,319 months.  

Disclosures: The study received no outside funding. Lead author Dr. Anna Glasier and coauthor Stephanie Sober disclosed serving as independent consultants to HRA-Pharma.

Source: Glasier A et al. Contraception. 2021 Sep 6. doi: 10.1016/j.contraception.2021.08.016.

Key clinical point: Daily use of 75 µg norgestrel was effective contraception for both breastfeeding and non-breastfeeding women

Major finding:  Overall failure rates for non-breastfeeding women using 75 µg/day norgestrel ranged from 0-2.4/100 woman-years for an aggregate Pearl Index of 2.2. Among breastfeeding women, the 12-month life table cumulative pregnancy rates for norgestrel ranged from 0-3.4.

Study details: The data come from 13 studies of women who used a progestogen-only pill containing 75 µg/day norgestrel. The review included 6 studies with data on 3,144 women who were not breastfeeding and 7 studies with data on 5,258 women who were breastfeeding during part of the follow-up period. The women were followed for a total of 35,319 months.  

Disclosures: The study received no outside funding. Lead author Dr. Anna Glasier and coauthor Stephanie Sober disclosed serving as independent consultants to HRA-Pharma.

Source: Glasier A et al. Contraception. 2021 Sep 6. doi: 10.1016/j.contraception.2021.08.016.

Key clinical point: Daily use of 75 µg norgestrel was effective contraception for both breastfeeding and non-breastfeeding women

Major finding:  Overall failure rates for non-breastfeeding women using 75 µg/day norgestrel ranged from 0-2.4/100 woman-years for an aggregate Pearl Index of 2.2. Among breastfeeding women, the 12-month life table cumulative pregnancy rates for norgestrel ranged from 0-3.4.

Study details: The data come from 13 studies of women who used a progestogen-only pill containing 75 µg/day norgestrel. The review included 6 studies with data on 3,144 women who were not breastfeeding and 7 studies with data on 5,258 women who were breastfeeding during part of the follow-up period. The women were followed for a total of 35,319 months.  

Disclosures: The study received no outside funding. Lead author Dr. Anna Glasier and coauthor Stephanie Sober disclosed serving as independent consultants to HRA-Pharma.

Source: Glasier A et al. Contraception. 2021 Sep 6. doi: 10.1016/j.contraception.2021.08.016.

Key clinical point: The contraception workforce in the United States varies by geography, provider specialty, and Medicaid acceptance, and gaps remain in the provision of IUDs and implants.

Major finding:  Approximately 73% of obgyns and nurse midwives prescribed the pill, patch, or ring, compared to 51% of family medicine physicians, 32% of pediatricians, and 20% of internal medicine physicians. A majority of obgyns provided contraception to Medicaid patients, ranging from 84% in the District of Columbia to 100% in North Dakota.

Study details: The data come from an observational study of the contraception workforce in the United States. A team of researchers created a comprehensive database of the workforce in the United States that provides six contraception types: intrauterine device (IUD), implant, shot (depot medroxyprogesterone acetate, or DMPA), oral contraception, hormonal patch, and vaginal ring. 

Disclosures: The study was funded by a private foundation that wishes to remain anonymous. The researchers had no financial conflicts to disclose.

Source: Chen C et al. Am J Obstet Gynecol. 2021 Aug 18. doi: 10.1016/j.ajog.2021.08.015.

Key clinical point: The contraception workforce in the United States varies by geography, provider specialty, and Medicaid acceptance, and gaps remain in the provision of IUDs and implants.

Major finding:  Approximately 73% of obgyns and nurse midwives prescribed the pill, patch, or ring, compared to 51% of family medicine physicians, 32% of pediatricians, and 20% of internal medicine physicians. A majority of obgyns provided contraception to Medicaid patients, ranging from 84% in the District of Columbia to 100% in North Dakota.

Study details: The data come from an observational study of the contraception workforce in the United States. A team of researchers created a comprehensive database of the workforce in the United States that provides six contraception types: intrauterine device (IUD), implant, shot (depot medroxyprogesterone acetate, or DMPA), oral contraception, hormonal patch, and vaginal ring. 

Disclosures: The study was funded by a private foundation that wishes to remain anonymous. The researchers had no financial conflicts to disclose.

Source: Chen C et al. Am J Obstet Gynecol. 2021 Aug 18. doi: 10.1016/j.ajog.2021.08.015.

Key clinical point: The contraception workforce in the United States varies by geography, provider specialty, and Medicaid acceptance, and gaps remain in the provision of IUDs and implants.

Major finding:  Approximately 73% of obgyns and nurse midwives prescribed the pill, patch, or ring, compared to 51% of family medicine physicians, 32% of pediatricians, and 20% of internal medicine physicians. A majority of obgyns provided contraception to Medicaid patients, ranging from 84% in the District of Columbia to 100% in North Dakota.

Study details: The data come from an observational study of the contraception workforce in the United States. A team of researchers created a comprehensive database of the workforce in the United States that provides six contraception types: intrauterine device (IUD), implant, shot (depot medroxyprogesterone acetate, or DMPA), oral contraception, hormonal patch, and vaginal ring. 

Disclosures: The study was funded by a private foundation that wishes to remain anonymous. The researchers had no financial conflicts to disclose.

Source: Chen C et al. Am J Obstet Gynecol. 2021 Aug 18. doi: 10.1016/j.ajog.2021.08.015.

A version of this article first appeared on Medscape.com.

A version of this article first appeared on Medscape.com.

A version of this article first appeared on Medscape.com.

A growing body of research suggests there may be an optimal duration of immunotherapy for patients with non-small cell lung cancer (NSCLC), after which it can be de-escalated or discontinued to minimize toxicity and costs while maintaining long-term efficacy.

However, the research to date does not provide a clear picture of which patients will achieve this “exceptional and durable response” and at which point patients can safely reduce or withdraw from treatment, according to Yasushi Goto, MD, PhD, a staff doctor in the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo.

Dr. Goto presented the latest evidence and explored the current unknowns surrounding immunotherapy de-escalation in NSCLC in a session this week at the virtual World Conference on Lung Cancer.

In addition to a toxicity and quality-of-life benefit for patients, immunotherapy de-escalation could have a significant impact on the costs of care, Dr. Goto stressed. The rising cost of new cancer treatments represents a “crisis” in terms of the affordability of health care, he said, and reducing these costs represents an “urgent global issue.”
 

Evidence on discontinuing treatment

Dr. Goto kicked off the session by emphasizing how drastically immunotherapy has enhanced outcomes for patients with NSCLC and other cancers.

This success has brought a pressing clinical question to the forefront: How long should we treat patients with immunotherapy?

The question arose over 10 years ago when ipilimumab (Yervoy) was granted FDA approval for patients with metastatic melanoma, but only for a total of four doses because of the drug’s toxicity.

“However, some patients had very lasting efficacy with the drug, even after discontinuation,” Dr. Goto said, which raised the exciting prospect that patients could achieve a functional cure with immunotherapy.

Evidence highlighting this lasting effect among patients with NSCLC soon emerged as well. A 2015 study, for instance, indicated that, despite toxicities, 50% of patients receiving nivolumab (Opdivo) continued to have a treatment effect more than 9 months after their last dose.

A 2021 analysis of patients receiving pembrolizumab (Keytruda) found that 48% of patients were disease-free after 5 years, despite having discontinued treatment after 2 years.

These investigators also found that toxicities accumulated over time – new grade greater than or equal to three toxicities occurred in 10% of patients every 6 months – which makes it particularly important to consider limiting the duration of therapy, Dr. Goto noted.

Only one randomized study to date – the CheckMate 153 trial – has explicitly explored outcomes associated with discontinuing immunotherapy in patients with NSCLC. In this study, patients still receiving nivolumab after 1 year were randomized to continue or stop therapy. Both median progression-free survival and overall survival were significantly longer in patients who continued therapy versus those who stopped at 1 year.  

However, Dr. Goto noted that limitations in the study design, including the fact that many patients were censored at an early stage, made the results “nonconfirmatory” and he would like to see more data.
 

The role of re-treatment

Finding the optimal time to discontinue treatment is critical but even if patients stop treatment before they achieve long-lasting benefits, they can still be retreated successfully.

Two recent studies examined the potential benefits of re-treatment. In the 2021 KEYNOTE-010 analysis, 21 patients received a second course of pembrolizumab, at a response rate of 53% and a disease control rate of 81%.

In another recent study, investigators found that among 78 patients with melanoma who had discontinued either nivolumab or pembrolizumab and were re-treated after disease progression, 15% (5 of 34) receiving a single anti-PD-1 agent responded to retreatment and 25% (11 of 44) escalated to nivolumab plus ipilimumab exhibited a response.

Dr. Goto noted that there are also ongoing randomized studies examining the optimal duration of immunotherapy in advanced melanoma. One that he is involved in, the SAVE study, is enrolling patients with advanced NSCLC who have responded to anti-PD-1 agents for over a year and will compare overall survival in those who stop therapy versus those who continue. In addition, given the “growing importance” of biomarkers as a prediction tool, Dr. Goto plans to integrate circulating tumor DNA testing to help identify patients more likely to benefit from therapy discontinuation.

If successful, such approaches could “disruptively decrease prescribing costs,” by lowering doses or dose frequency, shortening the treatment duration, or by substituting therapies with fewer adverse effects, Dr. Goto said.
 

Discussing de-escalation in practice

During the discussion period after his talk, session co-chair Loretta Erhunmwunsee, MD, City of Hope Comprehensive Cancer Center, Duarte, California, asked Dr. Goto what his current practice is in regard to de-escalation.

He replied that, in Japan, physicians are allowed to continue immunotherapy beyond 2 years, but “many patients stop their immune checkpoint inhibitor due to toxicity,” even if it is minor.

Exploring evidence surrounding the optimal duration of therapy, session cochair Bishal Gyawali, MD, PhD, Queen’s University, Kingston, Canada, pointed to collaborative studies in colon cancer that looked at chemotherapy duration, for example looking at 3 versus 6 months of treatment.

Dr. Gyawali wondered whether the same could be achieved in lung cancer to test the non-inferiority of shorter duration of immunotherapy versus continuing treatment until disease progression.

Dr. Goto noted that the biggest difference in the current context of NSCLC is the toxicity incurred by both the adjuvant chemotherapy and the immunotherapy, making the overall benefit to the patient “very difficult to show.” Consequently, patients may not be willing to join a randomized trial in which they could experience additional toxicity for uncertain benefit.

City of Hope oncologist H. Jack West, MD, who presented at the session, said he would “love to see more trials looking at de-escalation and seeing whether we do just as well on efficacy with lower toxicity and lower costs.”

Instead, “we are seeing reports of the fourth entrant into the field that just recapitulates things we already know,” which is “terribly disappointing.”

“I really wish we could vote with our feet more and not participate in trials that are completely redundant compared to what we’ve had for years already,” Dr. West said.

No funding for this study was declared. Dr. Goto disclosed relationships with AbbVie, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Chugai, Daiichi Sankyo, Eli Lilly, GlaxoSmithKline, Guardant Health, Illumina, Kyorin, MSD, Novartis, Ono Pharmaceutical, Pfizer, Shionogi Pharma, and Taiho Pharmaceutical. Dr. West disclosed relationships with AstraZeneca, EQRx, Genentech/Roche, Merck, Mirati, and Regeneron and is a regular contributor to Medscape Oncology.

A version of this article first appeared on Medscape.com.

A growing body of research suggests there may be an optimal duration of immunotherapy for patients with non-small cell lung cancer (NSCLC), after which it can be de-escalated or discontinued to minimize toxicity and costs while maintaining long-term efficacy.

However, the research to date does not provide a clear picture of which patients will achieve this “exceptional and durable response” and at which point patients can safely reduce or withdraw from treatment, according to Yasushi Goto, MD, PhD, a staff doctor in the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo.

Dr. Goto presented the latest evidence and explored the current unknowns surrounding immunotherapy de-escalation in NSCLC in a session this week at the virtual World Conference on Lung Cancer.

In addition to a toxicity and quality-of-life benefit for patients, immunotherapy de-escalation could have a significant impact on the costs of care, Dr. Goto stressed. The rising cost of new cancer treatments represents a “crisis” in terms of the affordability of health care, he said, and reducing these costs represents an “urgent global issue.”
 

Evidence on discontinuing treatment

Dr. Goto kicked off the session by emphasizing how drastically immunotherapy has enhanced outcomes for patients with NSCLC and other cancers.

This success has brought a pressing clinical question to the forefront: How long should we treat patients with immunotherapy?

The question arose over 10 years ago when ipilimumab (Yervoy) was granted FDA approval for patients with metastatic melanoma, but only for a total of four doses because of the drug’s toxicity.

“However, some patients had very lasting efficacy with the drug, even after discontinuation,” Dr. Goto said, which raised the exciting prospect that patients could achieve a functional cure with immunotherapy.

Evidence highlighting this lasting effect among patients with NSCLC soon emerged as well. A 2015 study, for instance, indicated that, despite toxicities, 50% of patients receiving nivolumab (Opdivo) continued to have a treatment effect more than 9 months after their last dose.

A 2021 analysis of patients receiving pembrolizumab (Keytruda) found that 48% of patients were disease-free after 5 years, despite having discontinued treatment after 2 years.

These investigators also found that toxicities accumulated over time – new grade greater than or equal to three toxicities occurred in 10% of patients every 6 months – which makes it particularly important to consider limiting the duration of therapy, Dr. Goto noted.

Only one randomized study to date – the CheckMate 153 trial – has explicitly explored outcomes associated with discontinuing immunotherapy in patients with NSCLC. In this study, patients still receiving nivolumab after 1 year were randomized to continue or stop therapy. Both median progression-free survival and overall survival were significantly longer in patients who continued therapy versus those who stopped at 1 year.  

However, Dr. Goto noted that limitations in the study design, including the fact that many patients were censored at an early stage, made the results “nonconfirmatory” and he would like to see more data.
 

The role of re-treatment

Finding the optimal time to discontinue treatment is critical but even if patients stop treatment before they achieve long-lasting benefits, they can still be retreated successfully.

Two recent studies examined the potential benefits of re-treatment. In the 2021 KEYNOTE-010 analysis, 21 patients received a second course of pembrolizumab, at a response rate of 53% and a disease control rate of 81%.

In another recent study, investigators found that among 78 patients with melanoma who had discontinued either nivolumab or pembrolizumab and were re-treated after disease progression, 15% (5 of 34) receiving a single anti-PD-1 agent responded to retreatment and 25% (11 of 44) escalated to nivolumab plus ipilimumab exhibited a response.

Dr. Goto noted that there are also ongoing randomized studies examining the optimal duration of immunotherapy in advanced melanoma. One that he is involved in, the SAVE study, is enrolling patients with advanced NSCLC who have responded to anti-PD-1 agents for over a year and will compare overall survival in those who stop therapy versus those who continue. In addition, given the “growing importance” of biomarkers as a prediction tool, Dr. Goto plans to integrate circulating tumor DNA testing to help identify patients more likely to benefit from therapy discontinuation.

If successful, such approaches could “disruptively decrease prescribing costs,” by lowering doses or dose frequency, shortening the treatment duration, or by substituting therapies with fewer adverse effects, Dr. Goto said.
 

Discussing de-escalation in practice

During the discussion period after his talk, session co-chair Loretta Erhunmwunsee, MD, City of Hope Comprehensive Cancer Center, Duarte, California, asked Dr. Goto what his current practice is in regard to de-escalation.

He replied that, in Japan, physicians are allowed to continue immunotherapy beyond 2 years, but “many patients stop their immune checkpoint inhibitor due to toxicity,” even if it is minor.

Exploring evidence surrounding the optimal duration of therapy, session cochair Bishal Gyawali, MD, PhD, Queen’s University, Kingston, Canada, pointed to collaborative studies in colon cancer that looked at chemotherapy duration, for example looking at 3 versus 6 months of treatment.

Dr. Gyawali wondered whether the same could be achieved in lung cancer to test the non-inferiority of shorter duration of immunotherapy versus continuing treatment until disease progression.

Dr. Goto noted that the biggest difference in the current context of NSCLC is the toxicity incurred by both the adjuvant chemotherapy and the immunotherapy, making the overall benefit to the patient “very difficult to show.” Consequently, patients may not be willing to join a randomized trial in which they could experience additional toxicity for uncertain benefit.

City of Hope oncologist H. Jack West, MD, who presented at the session, said he would “love to see more trials looking at de-escalation and seeing whether we do just as well on efficacy with lower toxicity and lower costs.”

Instead, “we are seeing reports of the fourth entrant into the field that just recapitulates things we already know,” which is “terribly disappointing.”

“I really wish we could vote with our feet more and not participate in trials that are completely redundant compared to what we’ve had for years already,” Dr. West said.

No funding for this study was declared. Dr. Goto disclosed relationships with AbbVie, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Chugai, Daiichi Sankyo, Eli Lilly, GlaxoSmithKline, Guardant Health, Illumina, Kyorin, MSD, Novartis, Ono Pharmaceutical, Pfizer, Shionogi Pharma, and Taiho Pharmaceutical. Dr. West disclosed relationships with AstraZeneca, EQRx, Genentech/Roche, Merck, Mirati, and Regeneron and is a regular contributor to Medscape Oncology.

A version of this article first appeared on Medscape.com.

A growing body of research suggests there may be an optimal duration of immunotherapy for patients with non-small cell lung cancer (NSCLC), after which it can be de-escalated or discontinued to minimize toxicity and costs while maintaining long-term efficacy.

However, the research to date does not provide a clear picture of which patients will achieve this “exceptional and durable response” and at which point patients can safely reduce or withdraw from treatment, according to Yasushi Goto, MD, PhD, a staff doctor in the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo.

Dr. Goto presented the latest evidence and explored the current unknowns surrounding immunotherapy de-escalation in NSCLC in a session this week at the virtual World Conference on Lung Cancer.

In addition to a toxicity and quality-of-life benefit for patients, immunotherapy de-escalation could have a significant impact on the costs of care, Dr. Goto stressed. The rising cost of new cancer treatments represents a “crisis” in terms of the affordability of health care, he said, and reducing these costs represents an “urgent global issue.”
 

Evidence on discontinuing treatment

Dr. Goto kicked off the session by emphasizing how drastically immunotherapy has enhanced outcomes for patients with NSCLC and other cancers.

This success has brought a pressing clinical question to the forefront: How long should we treat patients with immunotherapy?

The question arose over 10 years ago when ipilimumab (Yervoy) was granted FDA approval for patients with metastatic melanoma, but only for a total of four doses because of the drug’s toxicity.

“However, some patients had very lasting efficacy with the drug, even after discontinuation,” Dr. Goto said, which raised the exciting prospect that patients could achieve a functional cure with immunotherapy.

Evidence highlighting this lasting effect among patients with NSCLC soon emerged as well. A 2015 study, for instance, indicated that, despite toxicities, 50% of patients receiving nivolumab (Opdivo) continued to have a treatment effect more than 9 months after their last dose.

A 2021 analysis of patients receiving pembrolizumab (Keytruda) found that 48% of patients were disease-free after 5 years, despite having discontinued treatment after 2 years.

These investigators also found that toxicities accumulated over time – new grade greater than or equal to three toxicities occurred in 10% of patients every 6 months – which makes it particularly important to consider limiting the duration of therapy, Dr. Goto noted.

Only one randomized study to date – the CheckMate 153 trial – has explicitly explored outcomes associated with discontinuing immunotherapy in patients with NSCLC. In this study, patients still receiving nivolumab after 1 year were randomized to continue or stop therapy. Both median progression-free survival and overall survival were significantly longer in patients who continued therapy versus those who stopped at 1 year.  

However, Dr. Goto noted that limitations in the study design, including the fact that many patients were censored at an early stage, made the results “nonconfirmatory” and he would like to see more data.
 

The role of re-treatment

Finding the optimal time to discontinue treatment is critical but even if patients stop treatment before they achieve long-lasting benefits, they can still be retreated successfully.

Two recent studies examined the potential benefits of re-treatment. In the 2021 KEYNOTE-010 analysis, 21 patients received a second course of pembrolizumab, at a response rate of 53% and a disease control rate of 81%.

In another recent study, investigators found that among 78 patients with melanoma who had discontinued either nivolumab or pembrolizumab and were re-treated after disease progression, 15% (5 of 34) receiving a single anti-PD-1 agent responded to retreatment and 25% (11 of 44) escalated to nivolumab plus ipilimumab exhibited a response.

Dr. Goto noted that there are also ongoing randomized studies examining the optimal duration of immunotherapy in advanced melanoma. One that he is involved in, the SAVE study, is enrolling patients with advanced NSCLC who have responded to anti-PD-1 agents for over a year and will compare overall survival in those who stop therapy versus those who continue. In addition, given the “growing importance” of biomarkers as a prediction tool, Dr. Goto plans to integrate circulating tumor DNA testing to help identify patients more likely to benefit from therapy discontinuation.

If successful, such approaches could “disruptively decrease prescribing costs,” by lowering doses or dose frequency, shortening the treatment duration, or by substituting therapies with fewer adverse effects, Dr. Goto said.
 

Discussing de-escalation in practice

During the discussion period after his talk, session co-chair Loretta Erhunmwunsee, MD, City of Hope Comprehensive Cancer Center, Duarte, California, asked Dr. Goto what his current practice is in regard to de-escalation.

He replied that, in Japan, physicians are allowed to continue immunotherapy beyond 2 years, but “many patients stop their immune checkpoint inhibitor due to toxicity,” even if it is minor.

Exploring evidence surrounding the optimal duration of therapy, session cochair Bishal Gyawali, MD, PhD, Queen’s University, Kingston, Canada, pointed to collaborative studies in colon cancer that looked at chemotherapy duration, for example looking at 3 versus 6 months of treatment.

Dr. Gyawali wondered whether the same could be achieved in lung cancer to test the non-inferiority of shorter duration of immunotherapy versus continuing treatment until disease progression.

Dr. Goto noted that the biggest difference in the current context of NSCLC is the toxicity incurred by both the adjuvant chemotherapy and the immunotherapy, making the overall benefit to the patient “very difficult to show.” Consequently, patients may not be willing to join a randomized trial in which they could experience additional toxicity for uncertain benefit.

City of Hope oncologist H. Jack West, MD, who presented at the session, said he would “love to see more trials looking at de-escalation and seeing whether we do just as well on efficacy with lower toxicity and lower costs.”

Instead, “we are seeing reports of the fourth entrant into the field that just recapitulates things we already know,” which is “terribly disappointing.”

“I really wish we could vote with our feet more and not participate in trials that are completely redundant compared to what we’ve had for years already,” Dr. West said.

No funding for this study was declared. Dr. Goto disclosed relationships with AbbVie, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Chugai, Daiichi Sankyo, Eli Lilly, GlaxoSmithKline, Guardant Health, Illumina, Kyorin, MSD, Novartis, Ono Pharmaceutical, Pfizer, Shionogi Pharma, and Taiho Pharmaceutical. Dr. West disclosed relationships with AstraZeneca, EQRx, Genentech/Roche, Merck, Mirati, and Regeneron and is a regular contributor to Medscape Oncology.

A version of this article first appeared on Medscape.com.

Patients with life-limiting advanced lung cancer often experience intense grief and loss.

Addressing patients’ physical symptoms – drug side effects, trouble breathing, pain, fatigue – alongside their psychological and spiritual distress – depression, anxiety, fear of death – is critical to restoring their dignity and improving their quality of life, say palliative care experts.

Palliative care aims “to anticipate, prevent, and reduce suffering, promote adaptive coping, and support the best possible quality of life ... regardless of the stage of the disease or the need for other therapies,” commented Andreas Charalambous, RN, PhD, assistant professor (acting) of oncology and palliative care at the Cyprus University of Technology in Limassol, Cyprus.

He was speaking at the 2021 World Conference on Lung Cancer, where he chaired a special session entitled, “Grief and Loss in Palliative Care.”  

Research shows that the use of palliative care is associated with improved quality of life and lower costs of care for patients with cancer. But a 2015 Palliative Care Survey by the National Comprehensive Cancer Network found that although the majority of leading U.S. cancer centers have inpatient palliative care services, most reported insufficient capacity to meet the demand, and that home-based palliative care services and inpatient units were much less common.

Dr. Charalambous emphasized the importance of enhancing the use and quality of palliative care services for patients with advanced lung cancer.

During the session, experts discussed an array of strategies geared towards relieving physical symptoms as well as psychological and spiritual stressors.  
 

Physical activity: Establishing what’s possible

Grief and loss are “natural and normal” reactions to advanced cancer, commented Celia Marston, MPallCare, clinical lead for occupational therapy at Peter MacCallum Cancer Centre in Melbourne, Australia.

Patients experience feelings of loss around their independence, relationships, physical and cognitive functioning, which in turn impacts their sense of identity, daily routines, and plans for the future.

According to Ms. Marston, the rapid physical decline patients experience in the last 3 months of life is particularly “distressing,” which is why helping patients continue to perform everyday tasks is so critical. 

In clinical practice, this means providing patients palliative rehabilitation focused on maintaining at least a degree of their normal physical activity, which allows them “to adjust and contend with that decline,” Ms. Marston said. It also requires understanding what is important to patients and supporting those requests.

According to Ms. Marston, optimizing patient function can help maintain or slow that rate of physical decline, or sometimes improve it. But even partial activity can be “equally if not more important” than full participation in an activity. Patients “want to be active, they want to test what they can and can’t do” and establish what is possible, she said.
 

Nonpharmacological approaches to symptom control

Addressing strategies to relieve physical symptoms in patients with lung cancer, Alex Molassiotis, RN, PhD, chair professor of nursing at Hong Kong Polytechnic University, explored the role nonpharmacological interventions can play.

Dr. Molassiotis highlighted the 2021 American Society of Clinical Oncology guidelines for the Management of Dyspnea in Advanced Cancer, which discuss a range of nonpharmacological strategies to manage respiratory distress, in particular. These include supplemental oxygen and noninvasive ventilation as well as breathing techniques, posture, relaxation, meditation, physical and music therapy, and acupressure or reflexology.

In a 2015 randomized controlled feasibility trial, Dr. Molassiotis explored the effectiveness of one such strategy – inspiratory muscle training – in patients with lung cancer and reported improvements in the respiratory symptom cluster of breathlessness, cough, and fatigue. A 2020 trial of breathing retraining and psychosocial support for managing dyspnea in patients with lung cancer or mesothelioma also showed the intervention improved average dyspnea, control over dyspnea, and anxiety.

However, Dr. Molassiotis cautioned, many other nonpharmacological interventions have only “limited” evidence of effectiveness, and a “stronger evidence base” is required.

Physicians should nevertheless talk to patients about their respiratory symptoms and discuss the available options, taking into account the “major impact” these symptoms have on their quality of life.
 

Integrating psychological strategies

More than 40% of patients with advanced nonsmall cell lung cancer experience moderate to severe death anxiety, and about one in four patients with any stage of lung cancer experience significant depression and demoralization, research shows.

During the session, Gary Rodin, MD, of the Princess Margaret Cancer Centre in Toronto, stressed the “need to intervene” and outlined approaches relevant to different stages of the disease journey.

At the onset, he said, Emotion and Symptom-Focused Engagement (EASE) can help relieve patients’ physical symptoms and traumatic stress. Those with more advanced disease can receive Meaning-Centered Psychotherapy, or Managing Cancer and Living Meaningfully (CALM), which Dr. Rodin and his colleague Sarah Hales, MD, PhD, developed. And patients at the end of life may benefit from Dignity Therapy, a short form of psychotherapy focused on helping patients find comfort and meaning in their final days.  

Dr. Rodin focused on the role of CALM for those with advanced disease. CALM encompasses three to six sessions of a semi-structured intervention given over several months. The intervention focuses on four domains: 1. Symptom management and communication with healthcare providers; 2. Changes in oneself and relationships with others; 3. Spirituality, or finding a sense of meaning and purpose; and 4. Approaches to sustain hope and face mortality.

Dr. Rodin led a 2018 randomized trial comparing CALM with usual care, which showed the intervention was associated with significant reductions in depression symptoms and death anxiety in patients with advanced cancer at three and six months, as well as better patient communication and preparedness for the end of life. Patients reported that the intervention gave them “complete freedom” to communicate about themselves, their condition, and their life.

Evidence-based psychological interventions “should be offered as standard of care” to patients with lung cancer, Dr. Rodin said.
 

Enhancing patient-doctor communication

Having conversations early on about the goals of cancer care is particularly critical, according to Rachelle E. Bernacki, MD, director of quality initiatives, psychosocial oncology, and palliative care at the Dana-Farber Cancer Institute.

These conversations between physicians, patients, and family members give patients and loved ones time to make informed decisions, improve patients’ quality of care and satisfaction, and increase the likelihood of using hospice care, Dr. Bernacki explained.

But the reality is that these conversations don’t happen often enough. Less than one third of patients with end-stage diagnoses reported having an end-of-life discussion with their physician, and when the topic does arise, it is typically a few weeks before a patient passes away.

Moreover, these conversations “often fail to address key elements of quality discussions,” Dr. Bernacki commented.

Part of the problem is that many doctors lack the necessary training, face time constraints, or are uncertain about when or how to initiate these conversations.  

Although challenging, patients want to have these discussions. Nine of 10 Americans believe doctors should talk about end-of-life issues with their patients, and 75% of older patients want to know their prognosis so they can prepare for the future, make informed medical decisions, and optimize the time they have left.

Dr. Bernacki highlighted a framework that can help clinicians have productive end-of-life conversations with patients. The Serious Illness Conversation Guide, developed by Ariadne Labs and the Dana-Farber Cancer Institute, outlines key steps, which include scheduling the conversation, delivering a prognosis, and exploring what matters to the patient. The guide also explores how to communicate effectively with patients, such as asking permission and clarifying questions as well as engaging in active listening.

Above all, Dr. Bernacki stressed that physicians should “listen more than talk” and avoid providing premature assurance when addressing the prognosis. “Many fears will arise that cannot be fixed, but talking about them makes them more bearable for the patient,” she said.
 

Physicians experience grief, too

Patients with advanced lung cancer are not the only ones who face loss and distress. More than half of physicians treating terminally ill patients can experience burnout, according to Sonia Oyola, MD, assistant professor of family medicine at the University of Chicago Medicine.

In her presentation, Dr. Oyola highlighted strategies physicians can use to manage their grief.

The first step is simply acknowledging feelings of loss. But every physician will have a “unique way of grieving and caring for themselves,” she said.

In general, the literature supports several approaches for managing grief: engaging in death talks and self-attunement or personal awareness training as well as providing end-of-life education in medical schools.

On the personal awareness front, Dr. Oyola highlighted a narrative medicine exercise where physicians write about the patient and reflect on what moved or touched them, what surprised them, and what inspired them.

Pursuing this kind of exercise allows physicians to reflect on their experiences in a way “we often do not have the opportunity to do” and could prevent some of the “devastating consequences in our practices, such as burnout,” Dr. Oyola said.

No funding declared. Dr. Molassiotis has reported a relationship with Helsinn. No other relevant financial relationships declared.

A version of this article first appeared on Medscape.com.

Patients with life-limiting advanced lung cancer often experience intense grief and loss.

Addressing patients’ physical symptoms – drug side effects, trouble breathing, pain, fatigue – alongside their psychological and spiritual distress – depression, anxiety, fear of death – is critical to restoring their dignity and improving their quality of life, say palliative care experts.

Palliative care aims “to anticipate, prevent, and reduce suffering, promote adaptive coping, and support the best possible quality of life ... regardless of the stage of the disease or the need for other therapies,” commented Andreas Charalambous, RN, PhD, assistant professor (acting) of oncology and palliative care at the Cyprus University of Technology in Limassol, Cyprus.

He was speaking at the 2021 World Conference on Lung Cancer, where he chaired a special session entitled, “Grief and Loss in Palliative Care.”  

Research shows that the use of palliative care is associated with improved quality of life and lower costs of care for patients with cancer. But a 2015 Palliative Care Survey by the National Comprehensive Cancer Network found that although the majority of leading U.S. cancer centers have inpatient palliative care services, most reported insufficient capacity to meet the demand, and that home-based palliative care services and inpatient units were much less common.

Dr. Charalambous emphasized the importance of enhancing the use and quality of palliative care services for patients with advanced lung cancer.

During the session, experts discussed an array of strategies geared towards relieving physical symptoms as well as psychological and spiritual stressors.  
 

Physical activity: Establishing what’s possible

Grief and loss are “natural and normal” reactions to advanced cancer, commented Celia Marston, MPallCare, clinical lead for occupational therapy at Peter MacCallum Cancer Centre in Melbourne, Australia.

Patients experience feelings of loss around their independence, relationships, physical and cognitive functioning, which in turn impacts their sense of identity, daily routines, and plans for the future.

According to Ms. Marston, the rapid physical decline patients experience in the last 3 months of life is particularly “distressing,” which is why helping patients continue to perform everyday tasks is so critical. 

In clinical practice, this means providing patients palliative rehabilitation focused on maintaining at least a degree of their normal physical activity, which allows them “to adjust and contend with that decline,” Ms. Marston said. It also requires understanding what is important to patients and supporting those requests.

According to Ms. Marston, optimizing patient function can help maintain or slow that rate of physical decline, or sometimes improve it. But even partial activity can be “equally if not more important” than full participation in an activity. Patients “want to be active, they want to test what they can and can’t do” and establish what is possible, she said.
 

Nonpharmacological approaches to symptom control

Addressing strategies to relieve physical symptoms in patients with lung cancer, Alex Molassiotis, RN, PhD, chair professor of nursing at Hong Kong Polytechnic University, explored the role nonpharmacological interventions can play.

Dr. Molassiotis highlighted the 2021 American Society of Clinical Oncology guidelines for the Management of Dyspnea in Advanced Cancer, which discuss a range of nonpharmacological strategies to manage respiratory distress, in particular. These include supplemental oxygen and noninvasive ventilation as well as breathing techniques, posture, relaxation, meditation, physical and music therapy, and acupressure or reflexology.

In a 2015 randomized controlled feasibility trial, Dr. Molassiotis explored the effectiveness of one such strategy – inspiratory muscle training – in patients with lung cancer and reported improvements in the respiratory symptom cluster of breathlessness, cough, and fatigue. A 2020 trial of breathing retraining and psychosocial support for managing dyspnea in patients with lung cancer or mesothelioma also showed the intervention improved average dyspnea, control over dyspnea, and anxiety.

However, Dr. Molassiotis cautioned, many other nonpharmacological interventions have only “limited” evidence of effectiveness, and a “stronger evidence base” is required.

Physicians should nevertheless talk to patients about their respiratory symptoms and discuss the available options, taking into account the “major impact” these symptoms have on their quality of life.
 

Integrating psychological strategies

More than 40% of patients with advanced nonsmall cell lung cancer experience moderate to severe death anxiety, and about one in four patients with any stage of lung cancer experience significant depression and demoralization, research shows.

During the session, Gary Rodin, MD, of the Princess Margaret Cancer Centre in Toronto, stressed the “need to intervene” and outlined approaches relevant to different stages of the disease journey.

At the onset, he said, Emotion and Symptom-Focused Engagement (EASE) can help relieve patients’ physical symptoms and traumatic stress. Those with more advanced disease can receive Meaning-Centered Psychotherapy, or Managing Cancer and Living Meaningfully (CALM), which Dr. Rodin and his colleague Sarah Hales, MD, PhD, developed. And patients at the end of life may benefit from Dignity Therapy, a short form of psychotherapy focused on helping patients find comfort and meaning in their final days.  

Dr. Rodin focused on the role of CALM for those with advanced disease. CALM encompasses three to six sessions of a semi-structured intervention given over several months. The intervention focuses on four domains: 1. Symptom management and communication with healthcare providers; 2. Changes in oneself and relationships with others; 3. Spirituality, or finding a sense of meaning and purpose; and 4. Approaches to sustain hope and face mortality.

Dr. Rodin led a 2018 randomized trial comparing CALM with usual care, which showed the intervention was associated with significant reductions in depression symptoms and death anxiety in patients with advanced cancer at three and six months, as well as better patient communication and preparedness for the end of life. Patients reported that the intervention gave them “complete freedom” to communicate about themselves, their condition, and their life.

Evidence-based psychological interventions “should be offered as standard of care” to patients with lung cancer, Dr. Rodin said.
 

Enhancing patient-doctor communication

Having conversations early on about the goals of cancer care is particularly critical, according to Rachelle E. Bernacki, MD, director of quality initiatives, psychosocial oncology, and palliative care at the Dana-Farber Cancer Institute.

These conversations between physicians, patients, and family members give patients and loved ones time to make informed decisions, improve patients’ quality of care and satisfaction, and increase the likelihood of using hospice care, Dr. Bernacki explained.

But the reality is that these conversations don’t happen often enough. Less than one third of patients with end-stage diagnoses reported having an end-of-life discussion with their physician, and when the topic does arise, it is typically a few weeks before a patient passes away.

Moreover, these conversations “often fail to address key elements of quality discussions,” Dr. Bernacki commented.

Part of the problem is that many doctors lack the necessary training, face time constraints, or are uncertain about when or how to initiate these conversations.  

Although challenging, patients want to have these discussions. Nine of 10 Americans believe doctors should talk about end-of-life issues with their patients, and 75% of older patients want to know their prognosis so they can prepare for the future, make informed medical decisions, and optimize the time they have left.

Dr. Bernacki highlighted a framework that can help clinicians have productive end-of-life conversations with patients. The Serious Illness Conversation Guide, developed by Ariadne Labs and the Dana-Farber Cancer Institute, outlines key steps, which include scheduling the conversation, delivering a prognosis, and exploring what matters to the patient. The guide also explores how to communicate effectively with patients, such as asking permission and clarifying questions as well as engaging in active listening.

Above all, Dr. Bernacki stressed that physicians should “listen more than talk” and avoid providing premature assurance when addressing the prognosis. “Many fears will arise that cannot be fixed, but talking about them makes them more bearable for the patient,” she said.
 

Physicians experience grief, too

Patients with advanced lung cancer are not the only ones who face loss and distress. More than half of physicians treating terminally ill patients can experience burnout, according to Sonia Oyola, MD, assistant professor of family medicine at the University of Chicago Medicine.

In her presentation, Dr. Oyola highlighted strategies physicians can use to manage their grief.

The first step is simply acknowledging feelings of loss. But every physician will have a “unique way of grieving and caring for themselves,” she said.

In general, the literature supports several approaches for managing grief: engaging in death talks and self-attunement or personal awareness training as well as providing end-of-life education in medical schools.

On the personal awareness front, Dr. Oyola highlighted a narrative medicine exercise where physicians write about the patient and reflect on what moved or touched them, what surprised them, and what inspired them.

Pursuing this kind of exercise allows physicians to reflect on their experiences in a way “we often do not have the opportunity to do” and could prevent some of the “devastating consequences in our practices, such as burnout,” Dr. Oyola said.

No funding declared. Dr. Molassiotis has reported a relationship with Helsinn. No other relevant financial relationships declared.

A version of this article first appeared on Medscape.com.

Patients with life-limiting advanced lung cancer often experience intense grief and loss.

Addressing patients’ physical symptoms – drug side effects, trouble breathing, pain, fatigue – alongside their psychological and spiritual distress – depression, anxiety, fear of death – is critical to restoring their dignity and improving their quality of life, say palliative care experts.

Palliative care aims “to anticipate, prevent, and reduce suffering, promote adaptive coping, and support the best possible quality of life ... regardless of the stage of the disease or the need for other therapies,” commented Andreas Charalambous, RN, PhD, assistant professor (acting) of oncology and palliative care at the Cyprus University of Technology in Limassol, Cyprus.

He was speaking at the 2021 World Conference on Lung Cancer, where he chaired a special session entitled, “Grief and Loss in Palliative Care.”  

Research shows that the use of palliative care is associated with improved quality of life and lower costs of care for patients with cancer. But a 2015 Palliative Care Survey by the National Comprehensive Cancer Network found that although the majority of leading U.S. cancer centers have inpatient palliative care services, most reported insufficient capacity to meet the demand, and that home-based palliative care services and inpatient units were much less common.

Dr. Charalambous emphasized the importance of enhancing the use and quality of palliative care services for patients with advanced lung cancer.

During the session, experts discussed an array of strategies geared towards relieving physical symptoms as well as psychological and spiritual stressors.  
 

Physical activity: Establishing what’s possible

Grief and loss are “natural and normal” reactions to advanced cancer, commented Celia Marston, MPallCare, clinical lead for occupational therapy at Peter MacCallum Cancer Centre in Melbourne, Australia.

Patients experience feelings of loss around their independence, relationships, physical and cognitive functioning, which in turn impacts their sense of identity, daily routines, and plans for the future.

According to Ms. Marston, the rapid physical decline patients experience in the last 3 months of life is particularly “distressing,” which is why helping patients continue to perform everyday tasks is so critical. 

In clinical practice, this means providing patients palliative rehabilitation focused on maintaining at least a degree of their normal physical activity, which allows them “to adjust and contend with that decline,” Ms. Marston said. It also requires understanding what is important to patients and supporting those requests.

According to Ms. Marston, optimizing patient function can help maintain or slow that rate of physical decline, or sometimes improve it. But even partial activity can be “equally if not more important” than full participation in an activity. Patients “want to be active, they want to test what they can and can’t do” and establish what is possible, she said.
 

Nonpharmacological approaches to symptom control

Addressing strategies to relieve physical symptoms in patients with lung cancer, Alex Molassiotis, RN, PhD, chair professor of nursing at Hong Kong Polytechnic University, explored the role nonpharmacological interventions can play.

Dr. Molassiotis highlighted the 2021 American Society of Clinical Oncology guidelines for the Management of Dyspnea in Advanced Cancer, which discuss a range of nonpharmacological strategies to manage respiratory distress, in particular. These include supplemental oxygen and noninvasive ventilation as well as breathing techniques, posture, relaxation, meditation, physical and music therapy, and acupressure or reflexology.

In a 2015 randomized controlled feasibility trial, Dr. Molassiotis explored the effectiveness of one such strategy – inspiratory muscle training – in patients with lung cancer and reported improvements in the respiratory symptom cluster of breathlessness, cough, and fatigue. A 2020 trial of breathing retraining and psychosocial support for managing dyspnea in patients with lung cancer or mesothelioma also showed the intervention improved average dyspnea, control over dyspnea, and anxiety.

However, Dr. Molassiotis cautioned, many other nonpharmacological interventions have only “limited” evidence of effectiveness, and a “stronger evidence base” is required.

Physicians should nevertheless talk to patients about their respiratory symptoms and discuss the available options, taking into account the “major impact” these symptoms have on their quality of life.
 

Integrating psychological strategies

More than 40% of patients with advanced nonsmall cell lung cancer experience moderate to severe death anxiety, and about one in four patients with any stage of lung cancer experience significant depression and demoralization, research shows.

During the session, Gary Rodin, MD, of the Princess Margaret Cancer Centre in Toronto, stressed the “need to intervene” and outlined approaches relevant to different stages of the disease journey.

At the onset, he said, Emotion and Symptom-Focused Engagement (EASE) can help relieve patients’ physical symptoms and traumatic stress. Those with more advanced disease can receive Meaning-Centered Psychotherapy, or Managing Cancer and Living Meaningfully (CALM), which Dr. Rodin and his colleague Sarah Hales, MD, PhD, developed. And patients at the end of life may benefit from Dignity Therapy, a short form of psychotherapy focused on helping patients find comfort and meaning in their final days.  

Dr. Rodin focused on the role of CALM for those with advanced disease. CALM encompasses three to six sessions of a semi-structured intervention given over several months. The intervention focuses on four domains: 1. Symptom management and communication with healthcare providers; 2. Changes in oneself and relationships with others; 3. Spirituality, or finding a sense of meaning and purpose; and 4. Approaches to sustain hope and face mortality.

Dr. Rodin led a 2018 randomized trial comparing CALM with usual care, which showed the intervention was associated with significant reductions in depression symptoms and death anxiety in patients with advanced cancer at three and six months, as well as better patient communication and preparedness for the end of life. Patients reported that the intervention gave them “complete freedom” to communicate about themselves, their condition, and their life.

Evidence-based psychological interventions “should be offered as standard of care” to patients with lung cancer, Dr. Rodin said.
 

Enhancing patient-doctor communication

Having conversations early on about the goals of cancer care is particularly critical, according to Rachelle E. Bernacki, MD, director of quality initiatives, psychosocial oncology, and palliative care at the Dana-Farber Cancer Institute.

These conversations between physicians, patients, and family members give patients and loved ones time to make informed decisions, improve patients’ quality of care and satisfaction, and increase the likelihood of using hospice care, Dr. Bernacki explained.

But the reality is that these conversations don’t happen often enough. Less than one third of patients with end-stage diagnoses reported having an end-of-life discussion with their physician, and when the topic does arise, it is typically a few weeks before a patient passes away.

Moreover, these conversations “often fail to address key elements of quality discussions,” Dr. Bernacki commented.

Part of the problem is that many doctors lack the necessary training, face time constraints, or are uncertain about when or how to initiate these conversations.  

Although challenging, patients want to have these discussions. Nine of 10 Americans believe doctors should talk about end-of-life issues with their patients, and 75% of older patients want to know their prognosis so they can prepare for the future, make informed medical decisions, and optimize the time they have left.

Dr. Bernacki highlighted a framework that can help clinicians have productive end-of-life conversations with patients. The Serious Illness Conversation Guide, developed by Ariadne Labs and the Dana-Farber Cancer Institute, outlines key steps, which include scheduling the conversation, delivering a prognosis, and exploring what matters to the patient. The guide also explores how to communicate effectively with patients, such as asking permission and clarifying questions as well as engaging in active listening.

Above all, Dr. Bernacki stressed that physicians should “listen more than talk” and avoid providing premature assurance when addressing the prognosis. “Many fears will arise that cannot be fixed, but talking about them makes them more bearable for the patient,” she said.
 

Physicians experience grief, too

Patients with advanced lung cancer are not the only ones who face loss and distress. More than half of physicians treating terminally ill patients can experience burnout, according to Sonia Oyola, MD, assistant professor of family medicine at the University of Chicago Medicine.

In her presentation, Dr. Oyola highlighted strategies physicians can use to manage their grief.

The first step is simply acknowledging feelings of loss. But every physician will have a “unique way of grieving and caring for themselves,” she said.

In general, the literature supports several approaches for managing grief: engaging in death talks and self-attunement or personal awareness training as well as providing end-of-life education in medical schools.

On the personal awareness front, Dr. Oyola highlighted a narrative medicine exercise where physicians write about the patient and reflect on what moved or touched them, what surprised them, and what inspired them.

Pursuing this kind of exercise allows physicians to reflect on their experiences in a way “we often do not have the opportunity to do” and could prevent some of the “devastating consequences in our practices, such as burnout,” Dr. Oyola said.

No funding declared. Dr. Molassiotis has reported a relationship with Helsinn. No other relevant financial relationships declared.

A version of this article first appeared on Medscape.com.

Top 10 things to know about the AHA ACLS 2020 updates¹

1. There were no changes to the 2015 cardiac arrest algorithms.

2. The 2020 adult bradycardia algorithm increased the atropine dose to 1 mg (from 0.5-1 mg) but maintains the same frequency of dosing as every 3-5 minutes with max dose of 3 mg.

3. Epinephrine was reaffirmed. Specifically, give epinephrine as soon as possible in nonshockable rhythms (pulseless electrical activity and asystole). In shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia), the timing is less clear but it is reasonable to give the first dose after initial defibrillation attempts have failed. Currently the shockable rhythms algorithm has the first dose of epinephrine given after the second shock.

4. Giving medications intravenously is preferred over intraosseous (IO) cannulation because of some small observational studies that showed worsened outcomes with IO delivery. Try to get an IV if possible, but can still use IO if necessary. Central venous catheters are still not recommended during a code unless no other access can be obtained.

5. Double sequential defibrillation in refractory VF, which is the application of two sets of pads using two defibrillators to provide defibrillation either in rapid succession or at the same time, is not recommended because of lack of evidence.

6. It is reasonable to use physiological parameters such as arterial blood pressure or end-tidal CO₂ (EtCO₂) to monitor CPR quality. Goal EtCO₂ is greater than 10 but ideally greater 20 mm Hg, so if you’re not reaching that ideal goal, push harder and/or faster! Of note, to use arterial blood pressure monitoring you must have an arterial line in place and to get adequate EtCO2 monitoring, the patient must be intubated with an EtCO₂ monitor attached.

7. The need for intubation and the ideal timing are still unknown. The American Heart Association recommends either bag valve mask or an advanced airway.

8. In pregnant patients who develop cardiac arrest, focus on high-quality CPR and relief of aortocaval compression through left lateral uterine displacement while the patient is supine. This means that someone on the team stands on the left side of the patient and cups the uterus, pulling it up and leftward. Alternately, if standing on the right of the patient, push the uterus left and upward off of the maternal vessels.

9. AHA released new algorithms for opioid overdose given the current crisis. There is an absence of proven naloxone benefit in cardiac arrest so focus on standard resuscitative efforts and do not wait for effects of naloxone before initiating CPR. However, naloxone is still reasonable to give if overdose is suspected.

10. Clinicians should wait a minimum of 72 hours after return to normothermia before performing multimodal neuroprognostication. This allows for confounding factors (that is, meds) to hopefully be removed for improved accuracy.

Top 5 things that differ in a COVID-19+/PUI cardiac arrest case²

1. Don adequate personal protective equipment prior to entering the room. This might create a necessary delay in care.

2. Use a high-efficiency particulate air (HEPA) filter on all airway modalities.

3. Intubate as early as possible by someone highly experienced and place the patient on a ventilator with HEPA filter while undergoing resuscitation. This decreases aerosolization risk.

4. Use a mechanical CPR device if possible. This results in less people needed in the room.

5. If a patient is NOT intubated but is prone when they arrest, safely turn them supine and perform resuscitative effort. If a patient is intubated and prone when they arrest: If unable to safely turn them, place the pads in the AP position and perform compressions over T7-T10 vertebral bodies. Evidence for this is extremely limited but comes from a small pilot study which showed that reverse CPR generated a higher mean arterial pressure, compared with standard resuscitation.³

Dr. Allen is assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

References

1. Merchant RM et al. Part 1: Executive Summary: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020 Oct 21;142:S337-57. doi: 10.1161/CIR.0000000000000918.

2. Edelson DP et al. Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19. 2020 Jun 23;141(25):e933-43. doi: 10.1161/CIRCULATIONAHA.120.047463.

3. Mazer SP et al. Reverse CPR: A pilot study of CPR in the prone position. Resuscitation. 2003 Jun;57(3):279-85. doi: 10.1016/s0300-9572(03)00037-6.

Top 10 things to know about the AHA ACLS 2020 updates¹

1. There were no changes to the 2015 cardiac arrest algorithms.

2. The 2020 adult bradycardia algorithm increased the atropine dose to 1 mg (from 0.5-1 mg) but maintains the same frequency of dosing as every 3-5 minutes with max dose of 3 mg.

3. Epinephrine was reaffirmed. Specifically, give epinephrine as soon as possible in nonshockable rhythms (pulseless electrical activity and asystole). In shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia), the timing is less clear but it is reasonable to give the first dose after initial defibrillation attempts have failed. Currently the shockable rhythms algorithm has the first dose of epinephrine given after the second shock.

4. Giving medications intravenously is preferred over intraosseous (IO) cannulation because of some small observational studies that showed worsened outcomes with IO delivery. Try to get an IV if possible, but can still use IO if necessary. Central venous catheters are still not recommended during a code unless no other access can be obtained.

5. Double sequential defibrillation in refractory VF, which is the application of two sets of pads using two defibrillators to provide defibrillation either in rapid succession or at the same time, is not recommended because of lack of evidence.

6. It is reasonable to use physiological parameters such as arterial blood pressure or end-tidal CO₂ (EtCO₂) to monitor CPR quality. Goal EtCO₂ is greater than 10 but ideally greater 20 mm Hg, so if you’re not reaching that ideal goal, push harder and/or faster! Of note, to use arterial blood pressure monitoring you must have an arterial line in place and to get adequate EtCO2 monitoring, the patient must be intubated with an EtCO₂ monitor attached.

7. The need for intubation and the ideal timing are still unknown. The American Heart Association recommends either bag valve mask or an advanced airway.

8. In pregnant patients who develop cardiac arrest, focus on high-quality CPR and relief of aortocaval compression through left lateral uterine displacement while the patient is supine. This means that someone on the team stands on the left side of the patient and cups the uterus, pulling it up and leftward. Alternately, if standing on the right of the patient, push the uterus left and upward off of the maternal vessels.

9. AHA released new algorithms for opioid overdose given the current crisis. There is an absence of proven naloxone benefit in cardiac arrest so focus on standard resuscitative efforts and do not wait for effects of naloxone before initiating CPR. However, naloxone is still reasonable to give if overdose is suspected.

10. Clinicians should wait a minimum of 72 hours after return to normothermia before performing multimodal neuroprognostication. This allows for confounding factors (that is, meds) to hopefully be removed for improved accuracy.

Top 5 things that differ in a COVID-19+/PUI cardiac arrest case²

1. Don adequate personal protective equipment prior to entering the room. This might create a necessary delay in care.

2. Use a high-efficiency particulate air (HEPA) filter on all airway modalities.

3. Intubate as early as possible by someone highly experienced and place the patient on a ventilator with HEPA filter while undergoing resuscitation. This decreases aerosolization risk.

4. Use a mechanical CPR device if possible. This results in less people needed in the room.

5. If a patient is NOT intubated but is prone when they arrest, safely turn them supine and perform resuscitative effort. If a patient is intubated and prone when they arrest: If unable to safely turn them, place the pads in the AP position and perform compressions over T7-T10 vertebral bodies. Evidence for this is extremely limited but comes from a small pilot study which showed that reverse CPR generated a higher mean arterial pressure, compared with standard resuscitation.³

Dr. Allen is assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

References

1. Merchant RM et al. Part 1: Executive Summary: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020 Oct 21;142:S337-57. doi: 10.1161/CIR.0000000000000918.

2. Edelson DP et al. Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19. 2020 Jun 23;141(25):e933-43. doi: 10.1161/CIRCULATIONAHA.120.047463.

3. Mazer SP et al. Reverse CPR: A pilot study of CPR in the prone position. Resuscitation. 2003 Jun;57(3):279-85. doi: 10.1016/s0300-9572(03)00037-6.

Top 10 things to know about the AHA ACLS 2020 updates¹

1. There were no changes to the 2015 cardiac arrest algorithms.

2. The 2020 adult bradycardia algorithm increased the atropine dose to 1 mg (from 0.5-1 mg) but maintains the same frequency of dosing as every 3-5 minutes with max dose of 3 mg.

3. Epinephrine was reaffirmed. Specifically, give epinephrine as soon as possible in nonshockable rhythms (pulseless electrical activity and asystole). In shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia), the timing is less clear but it is reasonable to give the first dose after initial defibrillation attempts have failed. Currently the shockable rhythms algorithm has the first dose of epinephrine given after the second shock.

4. Giving medications intravenously is preferred over intraosseous (IO) cannulation because of some small observational studies that showed worsened outcomes with IO delivery. Try to get an IV if possible, but can still use IO if necessary. Central venous catheters are still not recommended during a code unless no other access can be obtained.

5. Double sequential defibrillation in refractory VF, which is the application of two sets of pads using two defibrillators to provide defibrillation either in rapid succession or at the same time, is not recommended because of lack of evidence.

6. It is reasonable to use physiological parameters such as arterial blood pressure or end-tidal CO₂ (EtCO₂) to monitor CPR quality. Goal EtCO₂ is greater than 10 but ideally greater 20 mm Hg, so if you’re not reaching that ideal goal, push harder and/or faster! Of note, to use arterial blood pressure monitoring you must have an arterial line in place and to get adequate EtCO2 monitoring, the patient must be intubated with an EtCO₂ monitor attached.

7. The need for intubation and the ideal timing are still unknown. The American Heart Association recommends either bag valve mask or an advanced airway.

8. In pregnant patients who develop cardiac arrest, focus on high-quality CPR and relief of aortocaval compression through left lateral uterine displacement while the patient is supine. This means that someone on the team stands on the left side of the patient and cups the uterus, pulling it up and leftward. Alternately, if standing on the right of the patient, push the uterus left and upward off of the maternal vessels.

9. AHA released new algorithms for opioid overdose given the current crisis. There is an absence of proven naloxone benefit in cardiac arrest so focus on standard resuscitative efforts and do not wait for effects of naloxone before initiating CPR. However, naloxone is still reasonable to give if overdose is suspected.

10. Clinicians should wait a minimum of 72 hours after return to normothermia before performing multimodal neuroprognostication. This allows for confounding factors (that is, meds) to hopefully be removed for improved accuracy.

Top 5 things that differ in a COVID-19+/PUI cardiac arrest case²

1. Don adequate personal protective equipment prior to entering the room. This might create a necessary delay in care.

2. Use a high-efficiency particulate air (HEPA) filter on all airway modalities.

3. Intubate as early as possible by someone highly experienced and place the patient on a ventilator with HEPA filter while undergoing resuscitation. This decreases aerosolization risk.

4. Use a mechanical CPR device if possible. This results in less people needed in the room.

5. If a patient is NOT intubated but is prone when they arrest, safely turn them supine and perform resuscitative effort. If a patient is intubated and prone when they arrest: If unable to safely turn them, place the pads in the AP position and perform compressions over T7-T10 vertebral bodies. Evidence for this is extremely limited but comes from a small pilot study which showed that reverse CPR generated a higher mean arterial pressure, compared with standard resuscitation.³

Dr. Allen is assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

References

1. Merchant RM et al. Part 1: Executive Summary: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020 Oct 21;142:S337-57. doi: 10.1161/CIR.0000000000000918.

2. Edelson DP et al. Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19. 2020 Jun 23;141(25):e933-43. doi: 10.1161/CIRCULATIONAHA.120.047463.

3. Mazer SP et al. Reverse CPR: A pilot study of CPR in the prone position. Resuscitation. 2003 Jun;57(3):279-85. doi: 10.1016/s0300-9572(03)00037-6.