Mélanome uvéal métastatique : étude descriptive d'un modèle d'intégration précoce des soins palliatifs

Background: uveal melanoma is a rare cancer. Up to 50% of patients develop metastasis, mainly hepatic. Prognosis is poor: median survival after metastasis is 12 months, in contrast with no significant symptom burden and a preserved overall condition until death. To assess the possibility of integrating early palliative care, we conducted the first pilot study to describe palliative care team activities and patient outcomes. Material and methods: from June 2016 to June 2018, 47 MUM patients began early, concomitant follow up by the oncologic and palliative teams at Institut Curie. Alongside clinical and biological features, data collection focused on symptoms and interventions of the palliative care team. Results: median age was 62 years (19-78), and median time to metastasis was 20 months (0-267). Median follow-up by the palliative team was 5 months (0-28). The first palliative care consultation occurred after a median time of 3 months (0-83) from the diagnosis of metastasis: 48,9% of patients were PS 0-1, and 78,7% were receiving systemic treatment for MUM. The main reason was the onset of symptoms for 42,6% (pain, malnutrition or anxiety), liver function tests impairment in 23,4% and stop of anti-cancer therapy in 4,3% of patients. It was a systematic joint consultation in 29,8%. At this first visit, we included social workers (8.5%) and nutritionists (4,3%). Antalgic and psychotrop prescriptions were needed for 36,2% and 27,7% of patients respectively. Over time, between 23 and 50% of patients experienced pain, but the most prevalent symptoms are anxiety and depression, experienced by 40 to 68% of the patients. At 9 months, antalgic prescriptions were needed for 53,8% and psychotrops for 61,5%,. Anti-cancer treatments were stopped in 93.6% of patients, mainly due to disease progression. 85,1%% of patients died of MUM, due to hepatic metastases, after a median time from metastasis of 14.5 months (1-107). A third of the patients died at home. Conclusions: despite few symptoms in comparison to other cancers, MUM patients could benefit from early palliative care to support needs and establish a life project. These issues will be investigated in a prospective study to assess the benefits of joint early oncological and palliative care in this rare melanoma.Introduction : le mélanome uvéal est un cancer rare. Jusqu’à 50 % des patients vont développer des métastases, principalement hépatiques. Le pronostic est sombre, la médiane de survie après rechute métastatique est de 12 mois, et contraste avec des patients pauci-symptomatiques et à l’état général conservé jusqu’à un stade avancé de la maladie. Pour explorer les possibilités d’intégration précoce des soins palliatifs, nous avons mené une étude pilote rétrospective afin de décrire les interventions de l’équipe de soins palliatifs et les caractéristiques cliniques des patients. Matériels et méthodes : entre Juin 2016 et juin 2018, 47 patients ont été suivis conjointement par les équipes d’oncologie et de soins palliatifs à l’Institut Curie à Paris. Les données clinico-biologiques, les symptômes et le type d’intervention de l’équipe de soins palliatives ont été recueillis de manière rétrospective. Résultats : l’âge médian des patients était de 62 ans (19-78), avec un délai médian entre le diagnostic initial et la rechute métastatique de 20 mois (0-267). La durée de suivi médian par l’équipe de soins palliatifs était de 5 mois (0-28). La première consultation en soins survenait dans un délai médian de 3 mois (0-83) après le diagnostic de rechute métastatique. 48,9 % des patients étaient OMS 0-1, et 78,7 % étaient en cours de traitement oncologique spécifique. La raison principale d’adressage à l’équipe de soins palliatifs était la survenue de symptômes pour 42,6 % (douleur, dénutrition ou anxiété), des perturbations du bilan hépatique pour 23,4 % et l’arrêt des traitements spécifiques pour 4,3 % des patients. Il s’agissait d’une consultation conjointe avec l’oncologue et le médecin de soins palliatifs dans 29,8 % des cas. A la première consultation, il y avait l’intervention d’assistants sociaux dans 8,5% des cas et de diététiciens dans 4,3% des cas. Une prescription d’antalgiques et de psychotropes était réalisée pour respectivement 36,2 % et 27,7 % des patients. Au cours du suivi, la douleur était présente chez 23 à 50 % des patients, mais les symptômes les plus prévalents étaient les symptômes anxio-dépressifs, survenant chez 40 à 68 % des patients. Au suivi à 9 mois, 53,8 % des patients étaient sous traitement antalgique et 61,5 % sous traitement psychotrope. Les traitements spécifiques étaient arrêtés pour 93,6 % d’entre eux, principalement en raison d’une altération de l’état général. Au terme de l’étude, 85,1% des patients étaient décédés, essentiellement par insuffisance hépatique dues aux lésions secondaires, après un délai médian de 14,5 mois (1-107) après le diagnostic de rechute. Un tiers des patients sont décédés au domicile. Conclusion : malgré des symptômes moins présents que pour d’autres localisations cancéreuses, les patients présentant un mélanome uvéal métastatique pourraient bénéficier d’une intégration précoce des soins palliatifs afin de pouvoir bénéficier d’une prise en charge globale et établir avec lui un projet de vie. Ces questions feront l’objet d’une étude prospective pour évaluer les bénéfices d’un suivi précoce conjoint en oncologie et en soins palliatifs dans ces rares situations

Palliative care in day-hospital for advanced cancer patients: a study protocol for a multicentre randomized controlled trial

International audienceBackground: Team-based and timely integrated palliative care is a gold standard of care in oncology, but issues concerning its optimal organization remain. Palliative Care in Day-Hospital (PCDH) could be one of the most efficient service model of palliative care to deliver interdisciplinary and multidimensional care addressing the complex supportive care needs of patients with advanced cancer. We hypothesize that, compared to conventional outpatient palliative care, PCDH allows the clinical benefits of palliative care to be enhanced.Methods/design: This study is a multicentre parallel group trial with stratified randomization. Patient management in PCDH will be compared to conventional outpatient palliative care. The inclusion criteria are advanced cancer patients referred to a palliative care team with an estimated life expectancy of more than 2 months and less than 1 year. The primary endpoint is health-related quality of life with deterioration-free survival based on the EORTC QLQ-C30 questionnaire. The secondary objectives are the following: increase in patient satisfaction with care using the EORTC PATSAT-C33 and OUT-PATSAT7 questionnaires, better understanding of the prognosis using the PTPQ questionnaire and advance care planning; decrease in the need for supportive care among relatives using the SCNS-P&C-F questionnaire, and reduction in end-of-life care aggressiveness. Patients will complete one to five questionnaires on a tablet before each monthly visit over 6 months and will be followed for 1 year. A qualitative study will take place, aiming to understand the specificity of palliative care management in PCDH. Cost-effectiveness, cost-utility and, an additional economic evaluation based on capability approach will be conducted from a societal point of view.Discussion: The first strength of this study is that it combines the main relevant outcomes assessing integrated palliative care; patient quality of life and satisfaction; discussion of the prognosis and advance care planning, family well-being and end-of-life care aggressiveness. The second strength of the study is that it is a mixed-method study associating a qualitative analysis of the specificity of PCDH organization, with a medical-economic study to analyse the cost of care

A Whole-Genome Single Nucleotide Polymorphism-Based Approach To Trace and Identify Outbreaks Linked to a Common Salmonella enterica subsp. enterica Serovar Montevideo Pulsed-Field Gel Electrophoresis Type

In this study, we report a whole-genome single nucleotide polymorphism (SNP)-based evolutionary approach to study the epidemiology of a multistate outbreak of Salmonella enterica subsp. enterica serovar Montevideo. This outbreak included 272 cases that occurred in 44 states between July 2009 and April 2010. A case-control study linked the consumption of salami made with contaminated black and red pepper to the outbreak. We sequenced, on the SOLiD System, 47 isolates with XbaI PFGE pattern JIXX01.0011, a common pulsed-field gel electrophoresis (PFGE) pattern associated with isolates from the outbreak. These isolates represented 20 isolates collected from human sources during the period of the outbreak and 27 control isolates collected from human, food, animal, and environmental sources before the outbreak. Based on 253 high-confidence SNPs, we were able to reconstruct a tip-dated molecular clock phylogeny of the isolates and to assign four human isolates to the actual outbreak. We developed an SNP typing assay to rapidly discriminate between outbreak-related cases and non-outbreak-related cases and tested this assay on an extended panel of 112 isolates. These results suggest that only a very small percentage of the human isolates with the outbreak PFGE pattern and obtained during the outbreak period could be attributed to the actual pepper-related outbreak (20%), while the majority (80%) of the putative cases represented background cases. This study demonstrates that next-generation-based SNP typing provides the resolution and accuracy needed for outbreak investigations of food-borne pathogens that cannot be distinguished by currently used subtyping methods