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      Identifying the need for specialized palliative care in adult cancer patients – development and validation of a screening procedure based on proxy assessment by physicians and filter questions

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          One challenge in caring for cancer patients with incurable disease is the adequate identification of those in need for specialized palliative care (SPC). The study’s aim was to validate an easy to use phenomenological screening tool.


          The German tool is based on the National Comprehensive Cancer Network (NCCN) Palliative Care guidelines and contains ten items in five domains that focus e.g. on diagnosis, functional status, complications, comorbidities, and palliative care relevant problems such as symptom management, distress, and support of family and team members. Sum score ranges from 0 to 14 (no need to great need). Assessment to identify SPC needs was done in university hospital wards between 1 and 08/2017 by health care professionals on admission of the patient if the disease was incurable and expected prognosis < 12 months. The Integrated Palliative Outcome Scale (IPOS, staff version), an outcome assessment instrument for palliative care that consists of ten items, served as external criterion; in sub samples inter-rater/test-retest were performed.


          Data from 208 patients with incurable disease and life expectancy < 12 months (54.8% female; average age 63.5 years, range 21–96) were assessed using the tool. The tool has good convergent validity; the correlation between the sum scores of IPOS and our tool showed a significant and substantial effect. The sum score was independent of the patient’s age, gender and primary diagnosis. Patients who already were in contact with SPC had significantly higher screening scores than patients without. With a cut point of  ≥ 5, 80.8% of the screened patients were in need for SPC. Cronbach’s alpha was α = .600. Rater agreement (inter-rater, test-retest) varied between single items. Correlation coefficients showed significant substantial effects.


          This is the first validation of a screening procedure in German language identifying SPC needs of adult patients with advanced cancer and the first using filter questions as a pre-screening. Proxy assessment of SPC needs by physicians in cancer care settings is feasible and the suggested tool presents a valid instrument to trigger a PC consultation.

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          The study was not registered.

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          Most cited references 12

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          Development and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT): a mixed-methods study

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            Trajectory of performance status and symptom scores for patients with cancer during the last six months of life.

            Ontario's cancer system is unique because it has implemented two standardized assessment tools population-wide to improve care: the Edmonton Symptom Assessment System (ESAS) measures severity of nine symptoms (scale 0 to 10; 10 indicates the worst) and the Palliative Performance Scale (PPS) measures performance status (scale 0 to 100; 0 indicates death). This article describes the trajectory of ESAS and PPS scores 6 months before death. Observational cohort study of cancer decedents between 2007 and 2009. Decedents required ≥1 ESAS or PPS assessment in the 6 months before death for inclusion. Outcomes were the decedents' average ESAS and PPS scores per week before death. Ten thousand seven hundred fifty-two (ESAS) and 7,882 (PPS) decedents were included. The mean age was 65 years, half were female, and approximately 75% of assessments occurred in cancer clinics. Average PPS score declined slowly over the 6 months before death, starting at approximately 70 and ending at 40, declining more rapidly in the last month. For ESAS symptoms, average pain, nausea, anxiety, and depression scores remained relatively stable over the 6 months. Conversely, shortness of breath, drowsiness, well-being, lack of appetite, and tiredness increased in severity over time, particularly in the month before death. More than one third of the cohort reported moderate to severe scores (ie, 4 to 10) for most symptoms in the last month of life. In this large outpatient cancer population, trajectories of mean ESAS scores followed two patterns: increasing versus generally flat. The latter was perhaps due to available treatment (eg, prescriptions) for those symptoms. Future research should prioritize addressing symptoms that worsen over time.
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              Standardizing integration of palliative care into comprehensive cancer therapy--a disease specific approach.

              Our comprehensive cancer centre adopted the WHO recommendation literally in the cancer care guidelines to implement the early integration (EI) of palliative care (PC). Evaluation of the first 2 years of this approach revealed that this guideline was too vague to trigger EI. As a consequence, an interdisciplinary working group was set up to propose and implement a more effective concept. An interdisciplinary (PC, oncology, radiotherapy, etc.) working group identified the need to (a) specify the timing of EI and (b) specify PC assignments by (c) providing more clear cut semantic and clinical definitions. As a result of repeated discussion in the different interdisciplinary working groups in charge of developing and consenting a once-yearly update of treatment guidelines [standard operating procedure (SOP)] for each malignancy, the need for disease-specific EI SOPs was identified. SOPs were developed for 19 malignancies (a) to identify a disease-specific point in each disease trajectory to initiate EI ("green flags") and to provide (b) a clear delineation and semantic differentiation of PC assignments ["palliative care" vs. "supportive" or "palliative therapies" ("green" vs. "red flags")]. To date, ASCO and WHO recommendations for EI lack detailed information about timing and infrastructure. The guidelines presented here aim to provide the missing information by reporting our developed and consented interdisciplinary guidelines for EI. With this concept, the authors provide a framework for realizing EI and hope to initiate a discussion about specific recommendations for EI.

                Author and article information

                +49-(0)9131-85-42514 ,
                BMC Cancer
                BMC Cancer
                BMC Cancer
                BioMed Central (London )
                1 July 2019
                1 July 2019
                : 19
                [1 ]Comprehensive Cancer Center CCC Erlangen – EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
                [2 ]Department of Palliative Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
                [3 ]Department of Internal Medicine 5, Haematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
                [4 ]Division of Respiratory Medicine, Department of Internal Medicine 1, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen , Erlangen, Germany
                [5 ]Department of Gynecology and Obstetrics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, University Breast Center Franconia, Erlangen, Germany
                [6 ]ISNI 0000 0000 9529 9877, GRID grid.10423.34, Institute for General Practice, , Hannover Medical School, ; Hannover, Germany
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

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