Cachectic patients frequently require transdermal fentanyl (TDF) for pain management, but data on its efficacy and safety are scarce and inconsistent. This scoping review aims to analyze the evidence concerning TDF administration in patients with cachexia irrespective of the underlying pathology. The primary objective is to assess the analgesic efficacy and tolerability of TDF in cachectic patients. The secondary objective is to identify cachexia characteristics that may influence fentanyl pharmacokinetics (PK). A comprehensive search of PubMed, Embase, and Web of Science databases was conducted up to March 2024. The review included observational and clinical studies on cachectic patients with moderate to severe pain treated with TDF patches at any dosage or frequency. Phase 1 trials, animal studies, case reports, preclinical studies and conference abstracts were excluded. Nine studies were included: four studies reported that cachexia negatively impacted TDF efficacy, increasing required doses and lowering plasma concentrations; three studies found minimal or no impact of cachexia on TDF efficacy and PK; two studies suggested that cachexia might improve TDF outcomes. Study quality ranged from moderate to high, according to the National Institutes of Health (NIH) Quality Assessment Tool. The current evidence is insufficient to provide any definitive recommendations for TDF prescribing in cachectic patients.

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/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). 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. Principal component analysis (PCA) and unsupervised K-means clustering (KMC) were used to identify SCs. Associations with ECOG performance status (PS), primary tumor site, 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 ± 15.28. PCA identified four SCs: SCPCA1 (tiredness, drowsiness, dyspnea, malaise), SCPCA2 (depression, anxiety), SCPCA3 (nausea, loss of appetite) and SCPCA4 (pain). KMC revealed three SCs: SCKMC1 (pain, tiredness, drowsiness, malaise), SCKMC2 (nausea, loss of appetite, dyspnea), SCKMC3 (depression, anxiety). Worse ECOG PS correlated significantly with physical SCs (p < 0.05). A trend linked SCKMC1 with greater PRT use. Psychological SCs (SCPCA2, SCKMC3) were significantly associated with a lower likelihood of receiving PRT. A trend toward shorter survival was observed among patients belonging to SCKMC2. Conclusions: SC analysis could improve clinical decision-making in the PRT setting. SC profiles reflect patient complexity and may guide personalized symptom management and treatment selection in advanced cancer.

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.

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.