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Key Points Most progressive strength and aerobic endurance training programmes have positive effects that last for 12 weeks Extended progressive strength training improves muscle strength for up to 24 months and aerobic endurance training increases walking capacity at 6–16 months Balance training improves balance, gait and mobility, and reduces falls for up to 12 months after completion of treatment Gait training improves gait performance and walking capacity for up to 6 months after training Tai chi and dance improve balance and tai chi reduces fall frequency up to 6 months after training A training period of at least 6 months is effective for achieving clinically meaningful improvement in UPDRS-III scores Exercise and physical therapy are important adjunct interventions to improve gait and balance impairments in patients with Parkinson disease (PD), as these features are inadequately treated by current pharmacological and surgical treatments. Here, Mak and colleagues discuss the long-term effects of exercise and physical therapy for PD, possible risks, recommendations for clinical practice, and emerging treatment approaches. Parkinson disease (PD) is a progressive, neurodegenerative movement disorder with symptoms reflecting various impairments and functional limitations, such as postural instability, gait disturbance, immobility and falls. In addition to pharmacological and surgical management of PD, exercise and physical therapy interventions are also being actively researched. This Review provides an overview of the effects of PD on physical activity — including muscle weakness, reduced aerobic capacity, gait impairment, balance disorders and falls. Previously published reviews have discussed only the short-term benefits of exercises and physical therapy for people with PD. However, owing to the progressive nature of PD, the present Review focuses on the long-term effects of such interventions. We also discuss exercise-induced neuroplasticity, present data on the possible risks and adverse effects of exercise training, make recommendations for clinical practice, and describe new treatment approaches. Evidence suggests that a minimum of 4 weeks of gait training or 8 weeks of balance training can have positive effects that persist for 3–12 months after treatment completion. Sustained strength training, aerobic training, tai chi or dance therapy lasting at least 12 weeks can produce long-term beneficial effects. Further studies are needed to verify disease-modifying effects of these interventions.

Key Points Patient referral to specialist palliative care is associated with improved quality of life, symptom control, patient and caregiver satisfaction, illness understanding, end-of-life care, costs of care, and, potentially, survival Oncologists and general practitioners have an important role in the delivery of primary palliative care, and in facilitating timely referral of patients to specialist palliative-care teams The integration of oncological and palliative care needs to be tailored to the demands of the individual health-care system and hospital setting, according to the resources available locally Outpatient palliative-care clinics are a hallmark of integration, providing patients with access to specialist palliative care early in the disease trajectory, and can accommodate multiple repeat visits over time Routine symptom screening with automatic referral criteria, combined (multidisciplinary) patient-care rounds, renaming palliative care to 'supportive care', and embedded oncology–palliative-care clinics represent potential strategies to encourage integration of care Education initiatives include a mandatory palliative-care rotation for oncology fellows, combined palliative care and oncology educational activities for trainees, and continuing medical education in palliative care for practicing oncologists The practice of palliative care for patients with cancer is continually improving, and an increasing evidence base indicates that early integration of oncological and palliative care can result in wide-ranging benefits for the patients, their loved ones, clinicians, and health-care payers. Herein, David Hui and Eduardo Bruera discuss optimization of clinical infrastructures, processes, and education to support this strategy, and provide a conceptual model for the integration of supportive and/or palliative care with primary and oncological care. The authors emphasize the need for health-care systems and institutions to tailor integration based on their resources, size, and the level of primary palliative care available. Over the past five decades, palliative care has evolved from serving patients at the end of life into a highly specialized discipline focused on delivering supportive care to patients with life-limiting illnesses throughout the disease trajectory. A growing body of evidence is now available to inform the key domains in the practice of palliative care, including symptom management, psychosocial care, communication, decision-making, and end-of-life care. Findings from multiple studies indicate that integrating palliative care early in the disease trajectory can result in improvements in quality of life, symptom control, patient and caregiver satisfaction, illness understanding, quality of end-of-life care, survival, and costs of care. In this narrative Review, we discuss various strategies to integrate oncology and palliative care by optimizing clinical infrastructures, processes, education, and research. The goal of integration is to maximize patient access to palliative care and, ultimately, to improve patient outcomes. We provide a conceptual model for the integration of supportive and/or palliative care with primary and oncological care. We also discuss how health-care systems and institutions need to tailor integration based on their resources, size, and the level of primary palliative care available.

Key Points Weight loss, owing to malnutrition is common in patients with oesophageal cancer and is often associated with worse clinical outcomes Cachexia in patients with oesophageal cancer is compounded by the location of the tumour and the fact that oesophageal cancer is often diagnosed at an advanced stage Cancer-treatment-related loss of body and muscle mass are substantial and should be considered as part of the cachexia syndrome observed in patients with oesophageal cancer Treatment with a curative intent involves exceptionally invasive surgery that often leads to profound postoperative weight loss and malnutrition, with adverse effects on both health-related quality of life and survival An unmet need exists for early identification of cachexia in patients with oesophageal cancer, with appropriate assessment tools for each of its major domains, throughout all of its clinical phases Management of patients with cachexia demands a complex multimodal approach, with early screening, nutrition support and mitigation of skeletal muscle loss Cachexia, a syndrome where metabolic demands cannot be met by energy intake, can substantially reduce the quality of life and increase mortality of patients with oesophageal cancer. In this Review, authors describe the causes, and effects of cachexia in these patients throughout the disease trajectory, and during the survivorship period; suggestions are made on how best to manage the effects of, and minimize the occurrence of this syndrome. Oesophageal cancer is a debilitating disease with a poor prognosis, and weight loss owing to malnutrition prevails in the majority of patients. Cachexia, a multifactorial syndrome characterized by the loss of fat and skeletal muscle mass and systemic inflammation arising from complex host–tumour interactions is a major contributor to malnutrition, which is a determinant of tolerance to treatment and survival. In patients with oesophageal cancer, cachexia is further compounded by eating difficulties owing to the stage and location of the tumour, and the effects of neoadjuvant therapy. Treatment with curative intent involves exceptionally extensive and invasive surgery, and the subsequent anatomical changes often lead to eating difficulties and severe postoperative malnutrition. Thus, screening for cachexia by means of percentage weight loss and BMI during the cancer trajectory and survivorship periods is imperative. Additionally, markers of inflammation (such as C-reactive protein), dysphagia and appetite loss should be assessed at diagnosis. Routine assessments of body composition are also necessary in patients with oesophageal cancer to enable assessment of skeletal muscle loss, which might be masked by sarcopenic obesity in these patients. A need exists for clinical trials examining the effectiveness of therapeutic and physical-activity-based interventions in mitigating muscle loss and counteracting cachexia in these patients.

The purpose of this 21-day assessor blinded, randomized-controlled trial was to compare an open-label placebo (OLP) to treatment as usual (TAU) for cancer survivors with fatigue. This was followed by an exploratory 21-day study in which TAU participants received OLPs while OLP participants in the main study were followed after discontinuing placebos. Cancer survivors (N = 74) who completed cancer treatment 6 months to 10 years prior to enrollment reporting at least moderate fatigue (i.e., ≥4 on a 0–10 scale) were randomized to OLP or TAU. Those randomized to OLP took 2 placebo pills twice a day for 21 days. Compared to those randomized to TAU, OLP participants reported a 29% improvement in fatigue severity (average difference in the mean change scores (MD) 12.47, 95% CI 3.32, 21.61; P = 0.008), medium effect (d = 0.63), and a 39% improvement in fatigue-disrupted quality of life (MD = 11.76, 95% CI 4.65, 18.86; P = 0.002), a large effect (d = 0.76). TAU participants who elected to try OLP for 21-days after the main study reported reductions in fatigue of a similar magnitude for fatigue severity and fatigue-disrupted quality of life (23% and 35%, respectively). OLP may reduce fatigue symptom severity and fatigue-related quality of life disruption in cancer survivors.

Health-care services are rapidly transforming their organization and workforce in response to the coronavirus disease 2019 (COVID-19) pandemic. These changes, and a desire to mitigate infection risk, are having profound effects on other vital aspects of care, including the care of patients with cancer. Difficult decisions are being made regarding the prioritization of both active treatments and palliative care, despite limited evidence that cancer is an independent risk factor for infection and mortality.

Primary dysmenorrhea, which is menstrual pain without pelvic pathology, is the most common gynecologic condition in women. Heat therapy has been used as a treatment. We assessed the evidence on heat therapy as a treatment for primary dysmenorrhea. We searched 11 databases for studies published through July 2018. All randomized controlled trials (RCTs) that addressed heat therapy for patients with primary dysmenorrhea were included. Data extraction and risk-of-bias assessments were performed by two independent reviewers. Risk of bias was assessed using the Cochrane risk-of-bias tool. Six RCTs met our inclusion criteria. Two RCTs found favorable effects of heat therapy on menstrual pain compared with unheated placebo therapy. Three RCTs found favorable effects of heating pads on menstrual pain compared with analgesic medication (n = 274; SMD −0.72; 95% confidence interval −0.97 to −0.48; P  < 0.001; two studies). One RCT showed beneficial effects of heat therapy on menstrual pain compared with no treatment (n = 132; MD −4.04 VAS; 95% CI −4.88 to −3.20; P < 0.001). However, these results are based on relatively few trials with small sample sizes. Our review provided suggestive evidence of the effectiveness of heat therapy for primary dysmenorrhea, but rigorous high-quality trials are still needed to provide robust evidence.

BackgroundWe modified and evaluated an advance care planning (ACP) intervention, which had been shown to improve compliance with patient’s end of life (EoL) wishes, in a different patient population.MethodsPatients with incurable cancer, and a Family Member (FM), were randomised one-to-one to usual care or usual care plus an ACP intervention, between April 2014 and January 2017. Oncologists and participants were non-blinded. ACP was based on the Respecting Patient Choices model, with an offer to provide individualised ranges for typical, best-case and worst-case scenarios for survival time. Seven facilitators (two oncology nurses, two nurses and three allied health professionals) delivered the intervention within 2 weeks of study enrolment. The primary outcome measure, assessed by interviewing the FM 3 months after patient death, was the FM perception that the patient’s wishes were discussed, and met.ResultsSix hundred and sixty-five patients from seven Australian metropolitan oncology centres were referred for consideration by their oncologists, 444 (67%) met the study inclusion criteria and were approached by a study researcher. Two hundred and eight patients (47%) and their FM entered the trial as dyads. Fifty-three (46%) dyads in the ACP group and 63 (54%) dyads in the usual-care group had complete primary outcome data (p = 0.16). Seventy-nine patients and 53 FMs attended an ACP discussion. Mean length of discussion was 57 min. FMs from 23 (43%) dyads allocated to ACP and 21 (33%) dyads allocated usual care reported the patient’s EoL wishes were discussed and met (difference 10%, 95% CI: −2 to 8, p = 0.27). There were no differences in EoL care received, patient satisfaction with care; FM satisfaction with care or with death; or FM well being. Rates of palliative care referral were high in both groups (97% vs 96%).ConclusionsA formal ACP intervention did not increase the likelihood that EoL care was consistent with patients’ preferences.

Digital health interventions (DHIs) have the potential to improve the accessibility and effectiveness of palliative care but heterogeneity amongst existing systematic reviews presents a challenge for evidence synthesis. This meta-review applied a structured search of ten databases from 2006 to 2020, revealing 21 relevant systematic reviews, encompassing 332 publications. Interventions delivered via videoconferencing (17%), electronic healthcare records (16%) and phone (13%) were most frequently described in studies within reviews. DHIs were typically used in palliative care for education (20%), symptom management (15%), decision-making (13%), information provision or management (13%) and communication (9%). Across all reviews, mostly positive impacts were reported on education, information sharing, decision-making, communication and costs. Impacts on quality of life and physical and psychological symptoms were inconclusive. Applying AMSTAR 2 criteria, most reviews were judged as low quality as they lacked a protocol or did not consider risk of bias, so findings need to be interpreted with caution.

Key Points The aim of the management of ALS is to maximize quality of life and minimize morbidity Guidelines for symptomatic care are becoming more evidenced-based Management by a specialist, clinic-based multidisciplinary team is associated with improved survival In patients with respiratory failure, noninvasive ventilation prolongs survival and improves quality of life Nutritional status is an independent predictor of survival and, if patients opt for enteral feeding, early gastrostomy insertion is recommended before significant weight loss takes place Cognitive impairment is common in ALS and is associated with a worse prognosis; the optimal management of this problem is unclear Although no cure exists for amyotrophic lateral sclerosis (ALS), supportive and symptomatic care can prolong survival and improve quality of life. This Review discusses best strategies to manage symptoms in patients with ALS, including respiratory and nutritional support. Such interventions should involve a specialist multidisciplinary team, and patient should be given an active role in planning of the care. The main aims in the care of individuals with amyotrophic lateral sclerosis (ALS) are to minimize morbidity and maximize quality of life. Although no cure exists for ALS, supportive and symptomatic care provided by a specialist multidisciplinary team can improve survival. The basis for supportive management is shifting from expert consensus guidelines towards an evidence-based approach, which encourages the use of effective treatments and could reduce the risk of harm caused by ineffective or unsafe interventions. For example, respiratory support using noninvasive ventilation has been demonstrated to improve survival and quality of life, whereas evidence supporting other respiratory interventions is insufficient. Increasing evidence implicates a causal role for metabolic dysfunction in ALS, suggesting that optimizing nutrition could improve quality of life and survival. The high incidence of cognitive dysfunction and its impact on prognosis is increasingly recognized, although evidence for effective treatments is lacking. A variety of strategies are used to manage the other physical and psychological symptoms, the majority of which have yet to be thoroughly evaluated. The need for specialist palliative care throughout the disease is increasingly recognized. This Review describes the current approaches to symptomatic and supportive care in ALS and outlines the current guidance and evidence for these strategies.

The purpose of this study was to investigate the mediating effect of death reflection on death literacy and death anxiety in clinical nurses. A sample of 2,882 nurses in China were selected by convenience sampling. A socio-demographic questionnaire, a death literacy scale, a death reflection scale, and a death anxiety scale were used to investigate. The results showed that death literacy was positively correlated with death reflection, but was negatively correlated with death anxiety. Furthermore, death literacy can influence death anxiety through the mediating effect of death reflection. We therefore suggest that relevant departments and institutions should seek optimal strategies to strengthen nurses’ death literacy training and promote death reflection in order to improve their death anxiety.