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Elmstedt, S., Mogensen, H., Hallmans, D.-E., Tavelin, B., Lundström, S. & Lindskog, M. (2019). Cancer patients hospitalised in the last week of life risk insufficient care quality - a population-based study from the Swedish Register of Palliative Care. Acta Oncologica, 58(4), 432-438
Open this publication in new window or tab >>Cancer patients hospitalised in the last week of life risk insufficient care quality - a population-based study from the Swedish Register of Palliative Care
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2019 (English)In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 58, no 4, p. 432-438Article in journal (Refereed) Published
Abstract [en]

Background: One-quarter of all cancer deaths in Sweden occur in hospitals. If the place of death affects the quality of end-of-life (EOL) is largely unknown.

Methods: This population-based, retrospective study included all adults cancer deaths reported to the Swedish Register of Palliative Care in 2011-2013 (N = 41,729). Hospital deaths were compared to deaths occurring in general or specialised palliative care, or in nursing homes with respect to care quality indicators in the last week of life. Odds ratios (OR) with 95% confidence intervals (CI) were calculated with specialised palliative home care as reference.

Results: Preferred place of death was unknown for 63% of hospitalised patients and consistent with the actual place of death in 25% compared to 97% in palliative home care. Hospitalised patients were less likely to be informed when death was imminent (OR: 0.3; CI: 0.28-0.33) as were their families (OR: 0.51; CI: 0.46-0.57). Validated screening tools were less often used in hospitals for assessment of pain (OR: 0.32; CI: 0.30-0.34) or other symptoms (OR: 0.31; CI: 0.28-0.34) despite similar levels of EOL symptoms. Prescriptions of as needed drugs against anxiety (OR: 0.27; CI: 0.24-0.30), nausea (OR: 0.19; CI: 0.17-0.21), or pulmonary secretions (OR: 0.29; CI: 0.26-0.32) were less prevalent in hospitals. Bereavement support was offered after 57% of hospital deaths compared to 87-97% in palliative care units and 72% in nursing homes.

Conclusions: Dying in hospital was associated with inferior end-of-life care quality among cancer patients in Sweden.

Place, publisher, year, edition, pages
TAYLOR & FRANCIS LTD, 2019
National Category
Nursing Other Medical Sciences not elsewhere specified
Identifiers
urn:nbn:se:uu:diva-382386 (URN)10.1080/0284186X.2018.1556802 (DOI)000463726300006 ()30633611 (PubMedID)
Available from: 2019-04-26 Created: 2019-04-26 Last updated: 2019-04-26Bibliographically approved
Stenman, M., Staehler, M., Szabados, B., Sandström, P., Laurell, A., Lindskog, M. & Harmenberg, U. (2019). Metastatic papillary renal cell carcinoma in the era of targeted therapy: a retrospective study from three European academic centres. Acta Oncologica, 58(3), 306-312
Open this publication in new window or tab >>Metastatic papillary renal cell carcinoma in the era of targeted therapy: a retrospective study from three European academic centres
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2019 (English)In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 58, no 3, p. 306-312Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Metastatic papillary renal cell carcinoma (mPRCC) is understudied. The disease is often aggressive and specific treatment options are lacking.

PATIENTS AND METHODS: mPRCC patients (n = 86) referred to three academic centres in Sweden and Germany in the years 2005-2015 were retrospectively identified from medical records. Statistical analyses included Kaplan-Meier curves and calculation of Cox proportional hazards, generating hazard ratios with 95% confidence intervals. The aim of the study was to evaluate overall survival (OS) of mPRCC patients treated outside of clinical trials in the era of targeted agents (TA) and to identify clinically useful prognostic factors.

RESULTS: Median OS of all mPRCC patients was 11.2 months. TA were used in 77% of the patients and associated with younger age and better Eastern Cooperative Oncology Group performance status (PS). Brain metastases were common (28%). Patients with synchronous or metachronous metastases had similar OS. Variables independently associated with risk of death included age ≥60 years, worse PS and ≥3 metastatic sites. The MSKCC criteria did not provide additional prognostic information. A subgroup analysis of TA-treated patients revealed an association of lymph node metastasis with risk of death in addition to the other prognostic factors.

CONCLUSION: OS in mPRCC remained short in the era of targeted agents. Age, PS, and number of metastatic sites provided independent prognostic information.

Keywords
metastatic, mRCC, non-clear cell, papillary, survival
National Category
Cancer and Oncology
Research subject
Oncology
Identifiers
urn:nbn:se:uu:diva-381855 (URN)10.1080/0284186X.2018.1537505 (DOI)000462947900007 ()30507262 (PubMedID)
Available from: 2019-04-15 Created: 2019-04-15 Last updated: 2019-08-20Bibliographically approved
Redig, J., Dalen, J., Harmenberg, U., Lindskog, M., Ljungberg, B., Lundstam, S., . . . Jakobsson, M. (2019). Real-world cost-effectiveness of targeted therapy in metastatic renal cell carcinoma in Sweden: a population-based retrospective analysis. Cancer Management and Research, 11, 1289-1297
Open this publication in new window or tab >>Real-world cost-effectiveness of targeted therapy in metastatic renal cell carcinoma in Sweden: a population-based retrospective analysis
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2019 (English)In: Cancer Management and Research, ISSN 1179-1322, Vol. 11, p. 1289-1297Article in journal (Refereed) Published
Abstract [en]

Objective: To explore cost-effectiveness of targeted therapies (TTs) in the treatment of metastatic renal cell carcinoma (mRCC) in a real-world context using a nationwide population-based approach.

Methods: Data on patients diagnosed with mRCC between 2002 and 2012 were extracted from Swedish national health data registers. To facilitate comparisons of patients diagnosed before and after TT introduction to the market, three cohorts were derived: pre-TT introduction (preTT), patients diagnosed 2002–2005; early TT introduction (TTi), patients diagnosed 2006–2008; and late TT introduction (TTii), which was limited to patients diagnosed 2009–2010 to ensure availability of total health care resource utilization (HCRU) data. Patients were followed until end of 2012. The value of TTs across cohorts was estimated using mean HCRU costs per life-year (LY) gained. Data on HCRU were obtained through national health registers for dispensed medication and inpatient and outpatient care, and the associated costs were estimated using the Lin method to account for censoring. LYs gained were defined as the difference in mean survival over the study period.

Results: The preTT, TTi, and TTii cohorts consisted of 1,366, 1,158, and 806 patients, respectively. Mean survival in years from mRCC diagnosis was 1.45 in the preTT cohort, 1.62 in the TTi cohort, and 1.83 in the TTii cohort. The respective mean total HCRU cost per patient over the study period was US$16,894, US$29,922, and US$30,037. The cost per LY gained per cohort was US$78,656 for TTi vs preTT, US$34,132 for TTii vs preTT, and US$523 for TTii vs TTi.

Conclusion: Given common willingness-to-pay per LY gained thresholds, this study in a real-world population suggests the use of TTs in the Swedish mRCC population is increasingly cost-effective over time.

Keywords
metastatic renal cell carcinoma, targeted therapy, cost-effectiveness, Sweden
National Category
Cancer and Oncology
Identifiers
urn:nbn:se:uu:diva-377704 (URN)10.2147/CMAR.S188849 (DOI)000458320200002 ()
Available from: 2019-02-25 Created: 2019-02-25 Last updated: 2019-02-25Bibliographically approved
Stenman, M., Sinclair, G., Paavola, P., Wersall, P., Harmenberg, U. & Lindskog, M. (2018). Overall survival after stereotactic radiotherapy or surgical metastasectomy in oligometastatic renal cell carcinoma patients treated at two Swedish centres 2005-2014. Radiotherapy and Oncology, 127(3), 501-506
Open this publication in new window or tab >>Overall survival after stereotactic radiotherapy or surgical metastasectomy in oligometastatic renal cell carcinoma patients treated at two Swedish centres 2005-2014
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2018 (English)In: Radiotherapy and Oncology, ISSN 0167-8140, E-ISSN 1879-0887, Vol. 127, no 3, p. 501-506Article in journal (Refereed) Published
Abstract [en]

Background and purpose: Investigate effects of stereotactic radiotherapy (SRT) or surgical metastasectomy (SM) on overall survival (OS) in metastatic renal cell carcinoma (mRCC) in the era of targeted agents (TA).

Material and methods: mRCC patients (n = 117) treated with SRT (n = 57), SM (n = 30) or both modalities sequentially (n = 30) at two oncological centres in Sweden in 2005-2014 were retrospectively included. Median follow-up (mFU) was 63 months.

Results: A majority had clear cell histology, 1-3 metastases, and ECOG performance status of 0 or 1. Two thirds had intermediate or poor risk and 44% synchronous metastases. 65% received TA. SRT patients were more likely to have adverse risk profiles. Median OS was 51 months without significant differences between SRT and SM. ECOG 1 vs 0 (HR 2.9; CI 1.6-5.2; p < 0.001), intracranial targets (HR 1.8; CI 1.1-3.2; p = 0.03) and watchful waiting >18 months prior to treatment (HR 0.3; CI 0.2-0.6; p = 0.001) were independently associated with OS. 15% of curatively treated patients (n = 60) were relapse-free with mFU of 87 months.

Conclusions: OS after SRT was comparable to SM and longer than expected considering patients with adverse risk profiles were common. Fit patients with non-brain metastases treated after an initial period of watchful waiting had the best prognosis.

Place, publisher, year, edition, pages
ELSEVIER IRELAND LTD, 2018
Keywords
Renal cell carcinoma, Stereotactic radiotherapy, Gamma knife, Surgical metastasectomy, Overall survival, Prognostic factors
National Category
Cancer and Oncology
Identifiers
urn:nbn:se:uu:diva-360494 (URN)10.1016/j.radonc.2018.04.028 (DOI)000437110000024 ()29754859 (PubMedID)
Available from: 2018-09-17 Created: 2018-09-17 Last updated: 2019-08-20Bibliographically approved
Lindskog, M., Wahlgren, T., Sandin, R., Kowalski, J., Jakobsson, M., Lundstam, S., . . . Harmenberg, U. (2017). Overall survival in Swedish patients with renal cell carcinoma treated in the period 2002 to 2012: Update of the RENCOMP study with subgroup analysis of the synchronous metastatic and elderly populations. Urologic Oncology, 35(9), Article ID 541.e15.
Open this publication in new window or tab >>Overall survival in Swedish patients with renal cell carcinoma treated in the period 2002 to 2012: Update of the RENCOMP study with subgroup analysis of the synchronous metastatic and elderly populations
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2017 (English)In: Urologic Oncology, ISSN 1078-1439, E-ISSN 1873-2496, Vol. 35, no 9, article id 541.e15Article in journal (Refereed) Published
Abstract [en]

Background: This retrospective study investigated overall survival (OS) and factors influencing OS in Swedish patients with metastatic renal cell carcinoma (mRCC) during the pre- (2002-2005), early (2006-2008), and late (2009-2012) targeted therapy (TT) era. Methods: Three national Swedish registries identified patients with mRCC. Median OS was estimated using the Kaplan-Meier method. Multivariate analysis was performed using Cox proportional hazards regression. Subgroup analysis was conducted for patients with synchronous metastases (Ml) and the elderly (aged >= 75 y). Results: A total of 4,217 patients with mRCC were identified, including 1,533 patients with Ml and 1,275 elderly patients. For patients with mRCC diagnosed in 2002 to 2005, 2006 to 2008, and 2009 to 2012, median OS was 10.0, 13.0, and 18.0 months. Similarly, median OS improved in the M1 and elderly populations. Elderly patients were less likely to be prescribed TT (>= 75 vs. <75 y): 18.3 vs. 63.5% (in 2006-2008) and 28.6% vs. 55.9% (in 2009-2012). Diagnosis of mRCC in 2009 to 2012, nephrectomy and TT prescription were associated with improved OS in the total mRCC, Ml, and elderly populations. Conclusion: This real-world study showed continued significant improvement in mRCC OS during the late TT era, including in Ml and elderly populations. TT should be considered for all patients with mRCC based on tolerability, regardless of age.

Keywords
Sweden, Renal cell carcinoma, Targeted therapy, Sunitinib, Survival
National Category
Urology and Nephrology Cancer and Oncology
Identifiers
urn:nbn:se:uu:diva-335870 (URN)10.1016/j.urolonc.2017.05.013 (DOI)000410681000009 ()
Available from: 2017-12-14 Created: 2017-12-14 Last updated: 2017-12-14Bibliographically approved
Lynoe, N., NattochDag, S., Lindskog, M. & Juth, N. (2016). Heed or disregard a cancer patient's critical blogging?: An experimental study of two different framing strategies. BMC Medical Ethics, 17, Article ID 30.
Open this publication in new window or tab >>Heed or disregard a cancer patient's critical blogging?: An experimental study of two different framing strategies
2016 (English)In: BMC Medical Ethics, ISSN 1472-6939, E-ISSN 1472-6939, Vol. 17, article id 30Article in journal (Refereed) Published
Abstract [en]

Background: We have examined healthcare staff attitudes of toward a blogging cancer patient who publishes critical posts about her treatment and their possible effect on patient-staff relationships and treatment decisions.

Methods: We used two versions of a questionnaire containing a vignette based on a modified real case involving a 39-year-old cancer patient who complained on her blog about how she was encountered and the treatment she received. Initially she was not offered a new, and expensive treatment, which might have influenced her perception of further encounters. In one version of the vignette, the team decides to put extra effort into both encounters and offers the expensive new cancer treatment. In the other version, the team decides to follow the clinic's routine to the letter. Subsequently, blog postings became either positive or negative in tone. We also divided participants into value-neutral and value-influenced groups (regarding personal values) by asking how their trust in healthcare would be affected if the team's suggestion were followed.

Results: A total of 56 % (95 % CI: 51-61) of the respondents faced with a team decision to 'do something-extra' in encounters would act in accordance with this ambition. Concerning treatment, 32 % (95 % CI: 28-38) would follow the team's decision to offer a new and expensive treatment. A large majority of those who received the "follow-routine" version agreed to do so in encountering [94 % (95 % CI: 91-97)]. Similar proportions were found regarding treatment [86 % (95 % CI: 82-90)]. A total of 83 % (95 % CI: 76-91) of the value-neutral participants who received the "do-something-extra" version stated that they would act as the team suggested regarding encounters, while 57 % (95 % CI: 47-67) would do so in regard to treatment. Among the value-influenced participants who received the "do-something-extra" version, 45 % (95 % CI: 38-51) stated that they would make an extra effort to accommodate the patient and her needs, while the proportion for treatment was 22 % (95 % CI: 16-27). Among those who had received the "follow-routine" version, a large majority agreed, and no difference was indicated between the value-neutral and the value-influenced participants.

Conclusion: The present study indicates that healthcare staff is indeed influenced by reading a patient's critical blog entries, largely regarding encounters, but also concerning treatment is concerned. Value-neutral healthcare personnel seem to exhibit a pragmatic attitude and be more inclined to heed and respond to a patient whose criticism may well be warranted. The study also indicates that healthcare staff is partly positive or negative to future blogging patients depending on how the issue has been framed. For future research we suggest as a bold hypothesis that the phrase "clinical routine" might conceal power aspects masquerading as adopted ethical principles.

Keywords
Blogging patients, Priority-setting, Decision-making, Social status, Tacit values
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-302250 (URN)10.1186/s12910-016-0115-3 (DOI)000376366200001 ()27207478 (PubMedID)
External cooperation:
Funder
Swedish Research CouncilForte, Swedish Research Council for Health, Working Life and Welfare, 2014 - 4024
Available from: 2016-09-01 Created: 2016-08-31 Last updated: 2017-11-21Bibliographically approved
Stenman, M., Nearchou, A. D., Sandström, P., Lindskog, M. & Harmenberg, U. (2016). Metastatic papillary renal cell carcinoma: A retrospective study from two large academic centers in Sweden. Paper presented at Genitourinary Cancers Symposium, JAN 07-09, 2016, San Francisco, CA. Journal of Clinical Oncology, 34(2)
Open this publication in new window or tab >>Metastatic papillary renal cell carcinoma: A retrospective study from two large academic centers in Sweden
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2016 (English)In: Journal of Clinical Oncology, ISSN 0732-183X, E-ISSN 1527-7755, Vol. 34, no 2Article in journal, Meeting abstract (Other academic) Published
Place, publisher, year, edition, pages
Uppsala Univ, Dept Immunol Genet & Pathol, Unit Expt & Clin Oncol, Uppsala, Sweden. Karolinska Inst, Dept Oncol & Pathol, Stockholm, Sweden.: , 2016
National Category
Cancer and Oncology
Identifiers
urn:nbn:se:uu:diva-300140 (URN)000378109100528 ()
Conference
Genitourinary Cancers Symposium, JAN 07-09, 2016, San Francisco, CA
Available from: 2016-08-03 Created: 2016-08-03 Last updated: 2017-11-28Bibliographically approved
Lindskog, M., Wahlgren, T., Sandin, R., Kowalski, J., Jakobsson, M., Lundstam, S., . . . Harmenberg, U. (2015). Overall survival (OS) in Swedish RCC patients treated 2000-2012: Update of the RENCOMP study. Paper presented at Genitourinary Cancers Symposium, FEB 26-28, 2015, Orlando, FL. Journal of Clinical Oncology, 33(7), Article ID 413.
Open this publication in new window or tab >>Overall survival (OS) in Swedish RCC patients treated 2000-2012: Update of the RENCOMP study
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2015 (English)In: Journal of Clinical Oncology, ISSN 0732-183X, E-ISSN 1527-7755, Vol. 33, no 7, article id 413Article in journal, Meeting abstract (Other academic) Published
National Category
Cancer and Oncology
Identifiers
urn:nbn:se:uu:diva-259216 (URN)000356886700410 ()
Conference
Genitourinary Cancers Symposium, FEB 26-28, 2015, Orlando, FL
Available from: 2015-07-30 Created: 2015-07-29 Last updated: 2017-12-04
Lindskog, M., Karvestedt, L. & Furst, C. J. (2014). Glycaemic control in end-of-life care: fundamental or futile?. Current Opinion in Supportive and Palliative Care, 8(4), 378-382
Open this publication in new window or tab >>Glycaemic control in end-of-life care: fundamental or futile?
2014 (English)In: Current Opinion in Supportive and Palliative Care, ISSN 1751-4258, Vol. 8, no 4, p. 378-382Article, review/survey (Refereed) Published
Abstract [en]

Purpose of review Diabetes mellitus is one of the most common comorbidities in palliative care. Yet, the optimal handling of diabetes mellitus in dying patients is debated. This review aims to discuss comprehensively the scientific basis as of today for diabetes mellitus management decisions in end-of-life (EOL) care. Recent findings Glycaemic control provides prognostic information in EOL care of diabetes mellitus patients. Original data on how to manage dying patients with type 2 diabetes mellitus are scarce. Findings in elderly type 2 diabetes mellitus patients and expert opinions support that glycaemic control should be relaxed in dying patients with type 2 diabetes mellitus, in the absence of risk factors for true insulin dependence, to avoid symptomatic hypoglycaemia. For terminal but conscious type 1 diabetes mellitus patients, regular blood glucose measurements and continued insulin therapy is the mainstay, with some discrepancy in preferred management between palliative care physicians and diabetes consultants. No randomized controlled trials are available. Improvement is clearly needed with regard to communication about diabetes mellitus in EOL and documentation of decisions. Corticosteroid-induced diabetes mellitus is a significant problem in palliative care, but predictors exist. Summary In the absence of large observational studies or randomized controlled trials, the current body of knowledge is based on expert opinions, surveys and retrospective studies. Nevertheless, some clinically meaningful recommendations can be made. Prospective studies need to be performed in order to improve our understanding about diabetes mellitus management in EOL. The palliative care community has a joint responsibility to address these questions.

National Category
Geriatrics
Identifiers
urn:nbn:se:uu:diva-240757 (URN)10.1097/SPC.0000000000000095 (DOI)000344737500011 ()25259543 (PubMedID)
Available from: 2015-01-08 Created: 2015-01-08 Last updated: 2015-01-08Bibliographically approved
Stenman, M., Laurell, A. & Lindskog, M. (2014). Prognostic significance of serum albumin in patients with metastatic renal cell carcinoma. Medical Oncology, 31(3), 841
Open this publication in new window or tab >>Prognostic significance of serum albumin in patients with metastatic renal cell carcinoma
2014 (English)In: Medical Oncology, ISSN 1357-0560, E-ISSN 1559-131X, Vol. 31, no 3, p. 841-Article in journal (Refereed) Published
Abstract [en]

Systemic inflammation has been suggested to impact on the prognosis of metastatic renal cell carcinoma (mRCC). We undertook a retrospective analysis of patients with mRCC treated at Akademiska University Hospital in Sweden during the years 2005-2012 to assess the possible prognostic significance of inflammation-related factors including serum albumin, platelet count, weight loss and C-reactive protein (CRP). The Memorial Sloan-Kettering Cancer Center (MSKCC) criteria for prognosis of mRCC and ECOG performance status were assessed for all patients. Overall survival (OS) and progression-free survival (PFS) were calculated according to Kaplan-Meier, and Cox proportional hazards regression was used for uni- and multivariate analyses. The median OS of all patients (n=84) was 20 months. Univariate analysis identified low serum albumin (HR=4.17, p<0.001), elevated platelet count (HR=2.98, p<0.001) and patient-reported weight loss prior to diagnosis of mRCC (HR=2.73, p<0.001), in addition to MSKCC (HR=3.35, p=0.0088) to be associated with shorter OS. CRP did not significantly affect OS. Serum albumin retained prognostic significance for OS in multivariate analysis (HR=2.72, p=0.015). In patients treated with an angiogenesis-targeted agent (n=47), low serum albumin level (HR=4.63, p<0.001) and elevated platelet count (HR=2.11, p=0.022) were associated with shorter PFS. In contrast, CRP, weight loss and MSKCC risk group did not significantly affect PFS. In multivariate analysis serum albumin remained associated with PFS (HR=3.92, p=0.0035). Our findings identify serum albumin as an independent prognostic factor for patients with mRCC treated with angiogenesis-targeted therapy.

National Category
Cancer and Oncology
Research subject
Oncology
Identifiers
urn:nbn:se:uu:diva-222546 (URN)10.1007/s12032-014-0841-7 (DOI)000337728700007 ()24477648 (PubMedID)
Available from: 2014-04-11 Created: 2014-04-11 Last updated: 2019-08-20Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0001-9484-1983

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