Integration of rehabilitation and palliative care in cancer management:A futuristic model

It explores the integration of rehabilitation and palliative care in cancer management,advocating for a holistic approach that addresses the diverse needs of patients throughout their treatment journey.Traditional cancer care often prioritizes curative interventions at the expense of overall well-being,leading to a fragmented experience for patients.By combining rehabilitation-focused on restoring function and improving physical health-with palliative care-emphasizing symptom management and quality of life-healthcare providers can create a comprehensive support system.The essay highlights the importance of interdisciplinary collaboration among healthcare professionals,as well as the need for education and training to implement this integrated model effectively.Additionally,it addresses potential barriers such as funding limitations and institutional resistance.Ultimately,the integration of these two disciplines represents a critical evolution in cancer care,enhancing patient outcomes and ensuring that individuals receive compassionate,patient-centered support throughout their journey.

Current interventional options for palliative care for patients with advanced-stage cholangiocarcinoma

Primary biliary tract tumors are malignancies that originate in the liver,bile ducts,or gallbladder.These tumors often present with jaundice of unknown etiology,leading to delayed diagnosis and advanced disease.Currently,several palliative treatment options are available for primary biliary tract tumors.They include percutaneous transhepatic biliary drainage(PTBD),biliary stenting,and surgical interventions such as biliary diversion.Systemic therapy is also commonly used for the palliative treatment of primary biliary tract tumors.It involves the administration of chemotherapy drugs,such as gemcitabine and cisplatin,which have shown promising results in improving overall survival in patients with advanced biliary tract tumors.PTBD is another palliative treatment option for patients with unresectable or inoperable malignant biliary obstruction.Biliary stenting can also be used as a palliative treatment option to alleviate symptoms in patients with unresectable or inoperable malignant biliary obstruction.Surgical interventions,such as biliary diversion,have traditionally been used as palliative options for primary biliary tract tumors.However,biliary diversion only provides temporary relief and does not remove the tumor.Primary biliary tract tumors often present in advanced stages,making palliative treatment the primary option for improving the quality of life of patients.

Facilitators and barriers to parent-child communication in pediatric palliative care:An integrative review

Objectives:This study aimed to identify facilitators and barriers to parent-child communication in pediatric palliative care,providing insights for medical professionals developing targeted interventions to enhance parent-child communication and improve its effectiveness.Methods:Whittemore and Knafl’s integrative review method was employed to guide a systematic search for literature in six databases(Medline,Embase,CINAHL Complete,PsycINFO,Web of Science,and Cochrane Library).Peer-reviewer articles published in the English language from inception to December 2023.All of the identified studies were screened,extracted,and analyzed independently by two researchers.Results:Twenty-four articles were included.Thefindings of the relevant studies were analyzed using thematic analysis.Four themes were identified as facilitators:legacy-making,resilience training programs,guidance from the healthcare team,and positive communication.Seven themes were identified as barriers:denial,being unprepared and evasive,mutual protection,being overwhelmed by painful emotions and overloaded with information,incorrect views of medical professionals and parents,negative communication,and cultural context.Conclusions:Parents and professionals should avoid myths about protecting the child and encourage open communication that respects the child’s wishes.The specialized pediatric palliative care team should carefully monitor parent-child communication,determine if any obstacles exist,and design more interventions to enhance it.

End-of-Life Inpatient Palliative Care for Glioblastoma Multiforme:Lessons Learned from One Case

Glioblastoma multiforme(GBM)is the most common malignant primary brain tumor with a poor prognosis and limited survival.Patients with GBM have a high demand for palliative care.In our present case,a 21-year-old female GBM patient received inpatient palliative care services including symptom management,mental and psychological support for the patient,psychosocial and clinical decision support for her family members,and pre-and post-death bereavement management for the family.Furthermore,we provided the family members with comprehensive psychological preparation for the patient's demise and assisted the patient's family throughout the mourning period.The aim of this study is to provide a reference and insights for the clinical implementation of palliative care for patients with malignant brain tumors.

Rôles et vécus des pharmaciens d’officine dans les soins palliatifsàdomicile en France Role and Experience ofCommunity Pharmacists in Home Palliative Care in France

The need for home palliative care is increasing in allWestern countries.Community pharmacists are local professionals whose role in end-of-life care at home remains poorly understood.The aim of this study is to understand how community pharmacists see their role in end-of-life home care in France,and to analyze their experiences of this care.An online questionnaire was distributed to community pharmacists working in France between December 2022 and March 2023.Of the 136 respondents to the questionnaire,87%had accompanied at least one patient at the end of life in the 3 months preceding the survey.Therapeutic education(88%of respondents),psychological support for caregivers(85%of respondents),securing treatment(82%of respondents)and monitoring therapeutic compliance(80%of respondents)are the behaviors validated by the greatest number of participants.The majority of professionals surveyed had a positive overall experience of managing patients at the end of life.These results pave the way for pharmacists to better support end-of-life patients at home.

Palliative care for end-stage liver disease and acute on chronic liver failure:A systematic review

BACKGROUND End stage liver disease(ESLD)represents a growing health concern characterized by elevated morbidity and mortality,particularly among individual ineligible for liver transplantation.The demand for palliative care(PC)is pronounced in patients grappling with ESLD and acute on chronic liver failure(ACLF).Unfortunately,the historical underutilization of PC in ESLD patients,despite their substantial needs and those of their family caregivers,underscores the imperative of seamlessly integrating PC principles into routine healthcare practices across the entire disease spectrum.AIM To comprehensively investigate the evidence surrounding the benefits of incorporating PC into the comprehensive care plan for individuals confronting ESLD and/or ACLF.METHODS A systematic search in the Medline(PubMed)database was performed using a predetermined search command,encompassing studies published in English without any restrictions on the publication date.Subsequently,the retrieved studies were manually examined.Simple descriptive analyses were employed to summarize the results.RESULTS The search strategies yielded 721 references.Following the final analysis,32 fulllength references met the inclusion criteria and were consequently incorporated into the study.Meticulous data extraction from these 32 studies was undertaken,leading to the execution of a comprehensive narrative systematic review.The review found that PC provides significant benefits,reducing symptom burden,depressive symptoms,readmission rates,and hospital stays.Yet,barriers like the appeal of transplants and misconceptions about PC hinder optimal utilization.Integrating PC early,upon the diagnosis of ESLD and ACLF,regardless of transplant eligibility and availability,improves the quality of life for these patients.CONCLUSION Despite the substantial suffering and poor prognosis associated with ESLD and ACLF,where liver transplantation stands as the only curative treatment,albeit largely inaccessible,PC services have been overtly provided too late in the course of the illness.A comprehensive understanding of PC's pivotal role in treating ESLD and ACLF is crucial for overcoming these barriers,involving healthcare providers,patients,and caregivers.

Palliative care with adequate pain relief challenges the need for euthanasia legislation

Background:In today’s society the ongoing discussion about euthanasia triggers emotionally charged debates surrounding the delicate balance between valuing life and respecting an individual’s autonomy.With the persistence of this debate,there has been the emergence of the concept of the so-called alternative:palliative care.Positioned as a substitute for euthanasia,palliative care aims to alleviate suffering in terminally ill patients without engaging in the ethical dilemmas associated with euthanasia.Methods:This paper explores the facets of palliative care highlighting its core objectives such as providing adequate pain relief as a compassionate alternative to euthanasia.Results:By examining palliative care as a comprehensive approach to end of life support,this study challenges the perceived necessity of euthanasia and advocates,for compassionate and dignified end of life experiences.Conclusion:In conclusion,palliative care emerges as a viable and ethically sound alternative to euthanasia,emphasizing the importance of compassionate end-of-life care and pain management.

Attitudes of nursing students about palliative care:an analysis of influencing factors

Background:As the population continues to age and the number of people suffering from incurable diseases,such as malignant tumors and Alzheimer’s disease,increases,the need for quality end-of-life care is becoming more and more prominent.Nursing students,as a reserved talent in the nursing field,have an attitude towards palliative care that will directly affect the quality of care for future terminal patients.Methods:This descriptive and cross-sectional survey was conducted from November 2020 to January 2021.A stratified sampling method randomly selected 1168 undergraduate and postgraduate nursing students as respondents.Students’attitudes were measured using a revised palliative care attitude questionnaire.Results:The palliative care attitude score was 7.233±1.812 with a score of 72.3%and a median score of 7.50 with a range of 0-10.63.10%of the nursing students had an attitude score of 7 or more and only 2.40%of the nursing students had a negative attitude towards palliative care.The results showed that gender,grade level,health status,and attitudes toward the nursing profession affected nursing students’attitudes toward palliative care(P<0.05).Conclusion:Currently,Chinese nursing students have better attitudes towards palliative care,but are less likely to want to pursue a career in palliative care in the future.Medical schools can take into account their actual gradual opening of palliative care courses,using a variety of teaching methods to stimulate the interest of nursing students to learn and improve their willingness to palliative care services.

Rapidly Progressing Hepatic Angiosarcoma Terminally Cared for at Home: A Case Discussion—Hepatic Angiosarcoma Taken Palliative Care at Home

Background: Hepatic angiosarcoma is a rare disease with a poor prognosis due to its tendency for distant sites. Few opportunities exist for palliative treatment of hepatic angiosarcomas at home. Here, we report a rare case of palliative treatment of hepatic angiosarcoma at home. Case Presentation: An 87-year-old male patient complained of upper abdominal pain and anorexia, persisting for 2 months. Computed tomography revealed multiple tumors in the liver, spleen, left kidney, and bone. Hepatic angiosarcoma was diagnosed based on the liver biopsy results. Due to his advanced age and dementia, the patient and his family decided to receive palliative treatment at home, thereby initiating home medical care at our clinic. During the first visit, oral opioid medication was introduced, and home oxygen therapy (HOT) was initiated because of complaints of cancer pain and respiratory distress. As oral intake became difficult, the patient was switched to a patch opioid, and suppositories were used for ton use. The patient was treated with morphine and HOT;however, the improvement in respiratory distress was below acceptable. The patient died at home on the ninth day after his visit. Conclusion: To the best of our knowledge, this is the first case report on palliative care for hepatic angiosarcoma at home. Owing to the rapid progression of this disease, home physicians must know its characteristics and provide appropriate medical care.

palliative care and end-stage colorectal cancer management:The surgeon meets the oncologist

Colorectal cancer (CRC) is a common neoplasia in the Western countries, with considerable morbidity and mortality. Every fifth patient with CRC presents with metastatic disease, which is not curable with radical intent in roughly 80% of cases. Traditionally approached surgically, by resection of the primitive tumor or stoma, the management to incurable stage IV CRC patients has significantly changed over the last three decades and is nowadays multidisciplinary, with a pivotal role played by chemotherapy (CHT). This latter have allowed for a dramatic increase in survival, whereas the role of colonic and liver surgery is nowadays matter of debate. Although any generalization is difficult, two main situations are considered, asymptomatic (or minimally symptomatic) and severely symptomatic patients needing aggressive management, including emergency cases. In asymptomatic patients, new CHT regimens allow today long survival in selected patients, also exceeding two years. The role of colonic resection in this group has been challenged in recent years, as it is not clear whether the resection of primary CRC may imply a further increase in survival, thus justifying surgery-related morbidity/mortality in such a class of short-living patients. Secondary surgery of liver metastasis is gaining acceptance since, under new generation CHT regimens, an increasing amount of patients with distant metastasis initially considered non resectable become resectable, with a significant increase in long term survival. The management of CRC emergency patients still represents a major issue in Western countries, and is associated to high morbidity/mortality. Obstruction is traditionally approached surgically by colonic resection, stoma or internal by-pass, although nowadays CRC stenting is a feasible option. Nevertheless, CRC stent has peculiar contraindications and complications, and its long-term cost-effectiveness is questionable, especially in the light of recently increased survival. Perforation is associated with the highest mortality and remains mostly matter for surgeons, by abdominal lavage/drainage, colonic resection and/or stoma. Bleeding and other CRC-related symptoms (pain, tenesmus, etc.) may be managed by several mini-invasive approaches, including radiotherapy, laser therapy and other transanal procedures.

Quality of life and palliative care needs of elderly patients with advanced heart failure

Objective To examine the quality of life and palliative care needs of elderly patients with advanced heart failure （HF）. Methods This was a correlation descriptive study conducted at a 650-bed sub-acute hospital. Patients who were aged 65 or over, diagnosed with HF of New York Heart Association Class III or IV symptoms, and mentally sound were eligible to the study. The Edmonton Symptom Assessment Scale, the overall quality of life single item scale, and the McQill Quality of Life Questionnaire （MQoL）, were used for measurement. Multi- ple regression analysis was performed to determine factors for predicting quality of life. Results A convenience sample of 112 patients was recruited. Their age was 81.5 ± 8.5 years. The three most distressing symptoms reported by the patients were tiredness （5.96 ± 2.78）, drowsiness （5.47± 2.93）, and shortness of breath （5.34 ± 2.96）. Their mean overall quality of life single item scale score was 4.72 ± 2.06 out of 10. The mean MQoL physical subscale score was the lowest （4.20 ± 1.767）, whereas their mean psychological subscale was the highest （7.14 ±2.39）. However, in a multivariate analysis model, quality of life was significantly associated with existential wellbeing, physical wellbeing, psychological wellbeing and educational level. Conclusions The findings highlight that spiritual concerns are significant palliative care needs among elderly patients with advanced HF, in addition to symptom management. This is in line with the argument that palliative care that places great emphasis on holistic care should be integrated to the care of this group of patients.

Inoperable esophageal cancer and outcome of palliative care

AIM:To determine the outcome of esophageal cancer patients referred for palliative care,in Gorgan and Gonbad gastrointestinal clinics,northeast of Iran. METHODS:This cross-sectional study was done on inoperable esophageal cancer cases referred to gastrointestinal clinics in Gorgan and Gonbad city(2005-2006) . Demographic data were collected during the procedure and cases were followed up every one month. Improvement proportion was calculated with 95% confidence interval,to determine the rate of improvement. Survival analysis and Kaplan-Meier methods were used to estimate the duration of palliative care effectiveness. RESULTS:We recruited 39 cases into the study. Squamous cell carcinoma was the most prevalent(92.3%) . The middle third of the esophagus was involved predominantly(51.3%) . Dilation was the most preferred method(89.7%) and stenting was done in 4 cases. Decreasing dysphagia score was not related to palliation method or pathology type of carcinoma. Age of the patients was significantly related to the improvement of dysphagia score. Mean survival time was 137.6 d and median was 103 d. CONCLUSION:Results of this study showed a low survival rate after palliative care in esophageal cancer cases despite dysphagia scores' improvement after dilating or stenting.

Palliative care needs and symptom burden in younger and older patients with end-stage renal disease undergoing maintenance hemodialysis:A cross-sectional study

Objectives:To investigate the current situation of palliative care needs and the symptom burden in patients with end-stage renal disease(ESRD)undergoing maintenance hemodialysis(MHD),and to explore whether there are differences between younger and older patients.Methods:This cross-sectional study was conducted in the hemodialysis centers of two tertiary hospitals from November 2021 to June 2022.Participants were selected by convenience sampling.Sociodemographics,clinical characteristics,the Palliative Care Outcome Scale(POS),the Dialysis Symptom Index(DSI),and health-related quality of life(EQ-5D-3L)were used for evaluation.Descriptive statistics,between-group comparisons,and correlation analysis were used to analyze the data.Results:A total of 236 patients were enrolled,including 118 younger and 118 older patients.The total median(P25,P75)POS score was 16.0(12.0,23.0),and the score was higher in older patients(P<0.01).The mean total number of symptoms in MHD patients was 15.04±5.06,and the overall median symptom severity score was 59.0(52.0,71.0);these scores were higher in the older group(P<0.01).The most common symptom was dry mouth(91.5%),followed by itching(83.1%),and dry skin(82.2%).Additionally,palliative care needs were significantly associated with symptom burden and health-related quality of life(HRQOL).Conclusions:The results showed that patients with ESRD undergoing MHD have a significant symptom burden and moderate palliative care needs,which are more severe in older patients.Therefore,interdisciplinary teams should be formed to actively manage patients’symptoms and meet the physical,psychological,social,and spiritual needs related to palliative care to improve patients’HRQOL.

Traumatic brain injury and palliative care:a retrospective analysis of 49 patients receiving palliative care during 2013–2016 in Turkey

Traumatic brain injury（TBI）,which is seen more in young adults,affects both patients and their families.The need for palliative care in TBI and the limits of the care requirement are not clear.The aim of this study was to investigate the length of stay in the palliative care center（PCC）,Turkey,the status of patients at discharge,and the need for palliative care in patients with TBI.The medical records of 49 patients with TBI receiving palliative care in PCC during 2013–2016 were retrospectively collected,including age and gender of patients,the length of stay in PCC,the cause of TBI,diagnosis,Glasgow Coma Scale score,Glas gow Outcome Scale score,Karnofsky Performance Status score,mobilization status,nutrition route（oral,percutaneous endoscopic gastrostomy）,pressure ulcers,and discharge status.These patients were aged 45.4 ± 20.2 years.The median length of stay in the PCC was 34.0 days.These included TBI patients had a Glasg ow Coma Scale score ≤ 8,were not mobilized,received tracheostomy and percutaneous endoscopic gastrostomy nutrition,and had pressure ulcers.No difference was found between those who were discharged to their home or other places（rehabilitation centre,intensive care unit and death） in respect of mobilization,percutaneous endoscopic gastrostomy,tracheostomy and pressure ulcers.TBI patients who were followed up in PCC were determined to be relatively young patients（45.4 ± 20.2 years） with mobilization and nutrition problems and pressure ulcer formation.As TBI patients have complex health conditions that require palliative care from the time of admittance to intensive care unit,provision of palliative care services should be integrated with clinical applications.

Individualized Treatment and Palliative Care for A90-Year-Old Patient with Primary Gastric Diffuse Large-B Cell Lymphoma:4 Year Follow-up and Inspiration

A 90-year-old man was diagnosed with primary gastric diffuse large B-cell lymphoma(PGDLBL)by PET/CT examination,gastroscopy,biopsy and histopathological analysis at a regular physical check in April,2016.The patient received R-CO chemotherapy(rituximab,cyclophosphamide,and vincristine)and radiotherapy subsequently,with enteral nutritional treatment through 3-cavity nasogastric tube due to development of pyloric obstruction.To satisfy patient's strong desire of eating by himself,we performed surgery of exploratory laparotomy and Roux-en-Y gastric bypass(RGB)to relieve pylorus obstruction.Postoperatively,the patient resumed oral feeding,supplemented by nasogastric tube feeding at 1350-1550 Kcal daily.He is now 94 years old with fairly well nutrition and normal communication.The outcome of 4 year follow-up suggests that nutritional treatment and palliative medicine are important for improving prognosis and life-quality of very elderly patients with end-stage tumors apart from the effective chemotherapy,radiotherapy,and surgery.

A retrospective study on use of palliative care for patients with alcohol related end stage liver disease in United States

BACKGROUND Palliative care(PC)has been shown to be beneficial in end stage liver disease(ESLD),yet the hospitalization data for PC utilization is unknown.AIM To identify the trend of PC utilization for the special population of alcoholassociated ESLD patients,factors affecting its use and ascertain its impact on healthcare utilization.METHODS We analyzed around 78 million discharges from the 2007-2014 national inpatient sample and 2010-2014 national readmission database including adult patients admitted for decompensated alcohol-associated cirrhosis.We identified patients with PC consultation as a secondary diagnosis.Odds ratios(OR)and means were adjusted for confounders using multivariate regression analysis models.RESULTS Out of the total 1421849 hospitalizations for decompensated liver cirrhosis,62782(4.4%)hospitalizations had a PC consult,which increased from 0.8%(1258)of all alcohol-associated ESLD hospitalizations in 2007 to 6.6%in 2014(P<0.01).Patient and hospital characteristics associated with increased odds of PC utilization were advanced age,lower income,Medicaid coverage,teaching institution,urban location,length of stay>3 d,prolonged ventilation,and administration of total parenteral nutrition(all P<0.01).Palliative encounters in alcohol-associated ESLD and acute-onchronic liver failure(ACLF)score were associated with increased odds of discharge to a rehabilitation facility,but significantly lower odds of 30-d readmissions(aOR:0.35,95%CI:0.31-0.41),lower total hospitalization charges and lower mean hospitalization days(all P<0.01).CONCLUSION Inpatient PC is sparingly used for patients with decompensated alcohol related liver disease,however it has increased over the past decade.PC consultation is associated with lower 30-d readmission rates on multivariate analysis,and lower hospitalization cost and length of stay in patients with ACLF score≥2.

Focuses and trends of the studies on pediatric palliative care:A bibliometric analysis from 2004 to 2018

Objectives:To investigate the focuses and trends of the studies on pediatric palliative care(PPC)and provide directions for future research.Methods:Relevant papers about PPC published from 2004 to 2018 were analyzed using bibliometric analysis methods,including co-word analysis,biclustering analysis,and strategic diagram analysis.The included papers were divided into three groups based on the publication time,including 2004-2008,2009-2013,and 2014-2018.Results:A total of 1132 papers were published between 2004 and 2018,and there were 293 papers published between 2004 and 2008,396 between 2009 and 2013,and 443 between 2014 and 2018.There were 42 high-frequency MeSH terms/MeSH subheadings in papers published between 2004 and 2018,including 12 between 2004 and 2008,13 between 2009 and 2013,and 17 between 2014 and 2018.Conclusion:Studies on PPC were making progress,with the increasing number,expanding scope,and uneven global distribution.Integration palliative care into pediatrics,cancer treatments in pediatric oncology,education methods on PPC,and establishment of professional teams were the major themes during 2004e2008,then the themes changed into establishing interventions to enhance the quality of life of the patients and parents,building professional-family relationship,and investigating attitude of health personnel in PPC during 2009-2013 and subsequently turned into communication skills,end-oflife decision making,and guidelines making on PPC during 2014-2018.Underdeveloped and protential themes including effective approaches to deal with the ethical dilemmas,training programs on communication skills,family support and guideline making are worth studying in the future.

Effective management for older people with heart failure： from acute to palliative care paradigms

Heart failure （HF） had emerged as an epidemic since two decades ago and is now a major threatening public health problem affecting 23 million population worldwide,

Reality of evidence-based practice in palliative care

There has been a paradigm shift in medicine away from tradition, anecdote and theoretical reasoning from the basic sciences towards evidence-based medicine(EBM). In palliative care however, statistically significant benefits may be marginal and may not be related to clinical meaningfulness. The typical treatment vs. placebo comparison necessitated by ‘gold standard' randomised controlled trials(RCTs) is not necessarily applicable. The complex multimorbidity of end of life care involves considerations of the patient's physical, psychological, social and spiritual needs. In addition, the field of palliative care covers a heterogeneous group of chronic and incurable diseases no longer limited to cancer. Adequate sample sizes can be difficult to achieve, reducing the power of studies and high attrition rates can result in inadequate follow up periods. This review uses examples of the management of cancer-related fatigue and death rattle(noisy breathing) to demonstrate the current state of EBM in palliative care. The future of EBM in palliative care needs to be as diverse as the patients who ultimately derive benefit. Non-RCT methodologies of equivalent quality, validity and size conducted by collaborative research networks using a ‘mixed methods approach' are likely to pose the correct clinical questions and derive evidencebased yet clinically relevant outcomes.

Gynecologic Oncologic Surgery for the Palliation of Life-Limiting Cancer Crises—The Importance of Education and Training in Palliative Care for the Gynecologic Oncologist

Introduction: Palliative care expertise is an important component of the comprehensive care of women with gynecologic cancers. Palliative care ranges from treatment of symptoms experienced by people with cancer such as constipation, nausea, anxiety, pain to careful and the skillful discussion of prognosis and goals of care. The purpose of this review is to summarize the basic issues in palliative care faced by healthcare providers caring for people with cancer and then focus on some examples of diagnostic and treatment dilemmas faced by gynecologic oncologists caring for women with recurrent cancers. Review Summary: Palliative and hospice care strategies are described. Palliative care refers to symptom management from diagnosis through active treatment, problems encountered by survivors, and concerns at the end of life. Hospice care pertains to care during the last six months of life and includes the alleviation of suffering of those dying from cancer and the support for family members. The symptoms at the end of life including pain, anorexia, and intestinal complications are reviewed. Palliative surgical procedures range from the drainage of pleural and abdominal fluid, including the management of intestinal obstruction via drains, diversionary procedures, or the creation of an ostomy. A comparison of outcomes between medical (when surgery was not feasible) and surgical management of bowel obstruction shows the average survival of 54 days compared to 193 days respectively. Conclusion: Gynecologic oncologists are uniquely positioned among other oncologists in managing intestinal obstruction, malignant ascites and pleural effusions, and oligometastatic recurrences where they must decide whether a medical or surgical approach will be effective in palliation and alleviation of suffering. The combination of traditional surgical gynecologic oncology training with palliative care is crucial to become the most effective clinician for each patient with advanced or recurrent gynecologic cancer.