Adjuvant radiotherapy (RT) plays an essential role in the management of early breast cancer (BC), but can lead to cardiovascular and lung toxicities. RT in deep inspiration breath hold (DIBH) often allows better protection of organs at risk. This prospective study compares surface-guided DIBH with free breathing (FB) in patients with left-sided BC, by evaluating individual cardiovascular risks and treatment plan dosimetry. The study enrolled 585 patients from October 2016 to January 2021 with left-sided invasive breast carcinoma with indicated adjuvant RT of the breast/thoracic wall with or without regional lymph nodes. The ability to hold breath for 20 s was a prerequisite. The treatments were either hypofractionated (HF; 40.05 Gy/15Fx) or normofractionated (NF; 50.00 Gy/25Fx). DIBH was applied using the automatically triggered surface guidance system Catalyst with audio-video feedback. Computed tomography and surface data were acquired during both DIBH and FB. The primary endpoint of the study was the comparative evaluation of heart dose reduction using DIBH. Plan dosimetry was significantly improved by DIBH. The mean and maximum doses to the heart and the left coronary artery were significantly reduced by 36%-42% in HF and NF plans (P < 0.001), while the mean ipsilateral lung dose was reduced by 12%-14% (P < 0.001). Furthermore, DIBH resulted in a 5% reduction in the cumulative 10-year cardiovascular disease risk (10-year cardiovascular disease risk) compared with FB (3.59% to 3.41%; P < 0.001). To the best of our knowledge, this is the largest prospective study showing better sparing for cardiac and ipsilateral lung doses with surface-guided DIBH compared with FB in patients with left-sided BC.

Background: Previous studies have often reported a link between advanced age and inadequate cancer pain management. Given Italy’s demographic profile as the country with the oldest population in Europe, it offers an ideal setting to explore whether this association remains valid today. Aim: This study aimed primarily to assess the influence of advanced age on the adequacy of pain management among patients receiving treatment in Italian radiotherapy (RT) departments, and secondarily, to identify age-specific determinants of analgesic undertreatment. Methods: In this prospective, multicenter study, we enrolled 2104 consecutive patients attending 13 RT centers between October and November 2019. Pain intensity was evaluated using the numeric rating scale (NRS), and patients reporting scores ≥ 1 (n = 1353) were included in the analysis. Pain management adequacy was assessed using the Pain Management Index (PMI), with negative values indicating undertreatment. A two-step statistical approach was employed: variable selection via Least Absolute Shrinkage and Selection Operator regression, followed by Classification and Regression Tree analysis to identify key predictors. Separate analyses were performed for the overall population, older adults (≥65 years), and younger adults (18–64 years). Results: Overall, 42% of patients were undertreated (PMI < 0), without significant differences between older (41.0%) and younger patients (43.1%). However, factors contributing to undertreatment varied according to age. For the entire cohort, non-cancer pain was associated with substantially higher rates of undertreatment (74.3%) compared to cancer-related pain (34.2%). Among cancer patients, those receiving curative RT had poorer pain control (49.4%) than those receiving palliative RT (28.8%). In older patients, geographic location strongly influenced pain management, with higher rates of undertreatment in central and southern Italy compared to the north (e.g., palliative RT: 64.0% vs. 15.4%, respectively). Conversely, younger patients showed no geographical differences; instead, timing of assessment (beginning vs. end of RT) influenced outcomes, with improved PMI values towards the end of treatment. Conclusions: Unlike previous studies, advanced age itself was not associated with inadequate analgesia. However, the determinants of inadequate pain management differed significantly by age: geographic disparities were predominant among older patients, while assessment timing influenced outcomes for younger patients. Further longitudinal research and targeted interventions are needed to address these age-dependent challenges.

Background: The increasing prevalence of chronic diseases makes identifying patients in need of palliative care essential for public health systems. Several tools have been developed to identify patients with palliative care needs and limited life expectancy. This study aimed to evaluate the performance of the NECPAL and PaP tools in patients with advanced chronic diseases and to explore their potential role in identifying palliative care needs and prognostic assessment. Methods: Prospective, observational, multicenter study using the Necesidades Paliativas tool (NECPAL CCOMS-ICO version 1.0), Palliative Prognostic score (PaP score), and functional and symptom assessment tools (Palliative Performance Scale and Edmonton Symptom Assessment System), assessed monthly or every two months for up to 12 months. Information on healthcare utilization and end-of-life care was also collected. Sensitivity, specificity, positive/negative predictive value and accuracy were calculated. The study included three groups of patients with advanced chronic diseases: cancer, pulmonary diseases, and renal diseases. The study was reported following the STROBE guidelines. Results: One hundred and ninety-three patients were enrolled: 102 with advanced cancer, 50 with chronic respiratory failure, and 41 with chronic renal failure. The median age was 75 years and 63.7% were male. The overall survival rate was 90% at 30 days and 65% at 12 months. At 30 days, sensitivity and specificity were 100% and 88% for the PaP score, and 89% and 39% for NECPAL. At 12 months, sensitivity and specificity were 20% and 89% for the PaP score, and 88% and 41% for NECPAL. Prognostic accuracy was higher for the PaP score at 30 days (91%) and higher for the NECPAL tool at 12 months (81%). Patients with cancer had more frequent hospitalizations in acute units, while the people living with pulmonary disease had more total hospitalization days. Conclusions: The findings suggest that the two instruments may provide complementary information, although the potential benefit of a combined strategy was not directly evaluated in this study.

Background: Methadone is a valuable drug for pain management but his use in palliative care settings is still challenging. The primary objective of this study was to take an in-depth look at the clinical use of methadone in specialized palliative care settings in Italy. Methods: A register of all active hospices in Italy at the time of the study was created by consulting the websites of the National Agency for Regional Health Services (Agenas) and the Italian Federation of Palliative Care (Federazione Cure Palliative). A telephone survey composed of an 18-item questionnaire was then carried out with a member of staff of each facility about the period between January and August 2023. A descriptive, non-statistical comparison was made between the results of the present survey and those obtained from a similar survey carried out in 2013. Results: Of the 275 hospices active at the time of the telephone survey, 160 (58%) responded to the questionnaire and 81 of them (51%) confirmed using methadone in their clinical practice. Questionnaire responses revealed that the perception of operators with regard to methadone has gradually shifted towards a greater appreciation of its strengths compared to the potential difficulties encountered in its use. In fact, the use of methadone increased over a 10-year period from 28% in 2013 to 51% in 2023. Conclusions: The results of the present study highlighted a considerable variability in the use of methadone in clinical practice, in line with literature data. Its use has substantially increased in recent years, but appropriate training of palliative care professionals is still needed to ensure its safe and effective management.

Background and Objectives: Effective palliative care relies on accurate identification and management of symptoms, especially in patients referred for palliative radiotherapy (PRT). This study aimed to identify symptom clusters (SCs)—defined as ≥2 interrelated symptoms—in patients evaluated at a multidisciplinary Radiotherapy and Palliative Care (RaP) outpatient clinic, using the Edmonton Symptom Assessment System (ESAS). Materials and Methods: We retrospectively analyzed data from patients referred to the RaP clinic between February 2017 and April 2020. Demographic and clinical characteristics, including ESAS scores at first visit, were collected. SCs were identified with principal component analysis (PCA) and unsupervised k-means clustering (KMC), determining the number of SCs based on the maximum gap statistic and interpretability. Associations with ECOG performance status (PS), primary tumor and metastases site, and PRT administration were analyzed. Exploratory survival analyses were performed. Results: Among 215 patients (median age = 71 years; 53% male), the mean total ESAS score was 24.03 (SD = 15.28). PCA identified four SCs: SC_PCA1 (tiredness, drowsiness, dyspnea, malaise), SC_PCA2 (depression, anxiety), SC_PCA3 (nausea, loss of appetite) and SC_PCA4 (pain). KMC revealed three SCs: SC_KMC1 (pain, tiredness, drowsiness, malaise), SC_KMC2 (nausea, loss of appetite, dyspnea), and SC_KMC3 (depression, anxiety). Worse ECOG PS correlated with physical SCs (p < 0.05). Psychological SCs were associated with lower likelihood of receiving PRT (OR_PCA2 = 0.26, CI: 0.07–0.80, OR_kmc3 = 0.19, CI: 0.02–0.85, p < 0.05), but when associated with pain/systemic clusters correlated with greater PRT use. A trend toward shorter survival was seen in SC_KMC2. Conclusions: SC analysis could improve personalized symptom management and clinical decision-making in the PRT setting.

The optimal sequence of chemo/immuno- and radiotherapy (RT) in metastatic non-small-cell lung cancer (NSCLC) remains challenging. Here, we describe the case of a 58-year-old female patient with an initially metastasized NSCLC obtaining local and distance durable response after chemo-immunotherapy and local RT associated with immunotherapy maintenance. Our experience offers a valuable perspective in choosing how to combine therapies to ensure the longest possible response in patients with estimated poor prognosis.