Trajectory of End-of-Life Pain and Other Physical Symptoms among Cancer Patients Receiving Home Care

Round 1

Reviewer 1 Report

Dear authors,

Thank you for submitting your work to the journal. You describe the trajectory of physical symptoms in a cohort of 27,295 cancer patients, followed between 2007 and 2014. Patients have used home care services at least once. The results included physical symptoms. Among these, you reported the incidence of pain, loss of appetite, shortness of breath, high health instability, and self-reported poor health. Not surprisingly, the multivariable regression model identified, as risk factors for physical symptoms in the last 3 months of life, caregiver distress, high health instability, social decline, pain uncontrolled and signs of depression.

The value of this large series is to give a clear picture of what can happen in such a large cohort, guiding future developments.

The paper could however be presented in its presentation, and more specifically the graphics and the table 3. I would suggest changing the x-axis by combining the time in weeks and a time table placed under (i.e. the number of patients considered at each time point, as in an survival analysis), in place of associating number and week as one item (less readable). The font size can be a little larger and unnecessary gridlines can be removed. Each graph area could be outlined by a line, composed on two sides by the x and the y axes.

Table 3 could be elegantly replaced by a forest plot with the odds ratios, and the current table 3 could be appended as an appendix.

Author Response

Thank you for your comments. We have taken your suggestions.

For the graphics of Figures 1 and 2, we have: modified the x-axis, so it is easier to read (with the n’s as a separate line underneath—like how it would be presented in a survival analysis); made the font size larger; and outlined each graph area.

As suggested, we have converted Table 3 into a single Figure of Forest plots. It indeed looks better and more elegant.

Reviewer 2 Report

This is an excellent study and well-performed by the authors. The topic of study is of high importance for trajectory of end-of-life pain and other physical symptoms among cancer patients receiving home care. As a reader it was enjoyable to read the article and as a reviewer I could not suggest any modifications in the content.

Author Response

Thank you. We are glad you enjoyed reading the manuscript.

Reviewer 3 Report

The Authors present a paper titled: Trajectory of end-of-life pain and other physical symptoms among cancer patients receiving home care. The paper is very well structured reporting a very large number of subjects in a long time observation.

Material and methods are adequate as well as the reported results . Figure 1 and 2 need a more detailed explanation or better a comment from Authors for better underline their meaning.

Discussion should be improved adding some practical suggestion from their experience. What is the final goal of the manuscript? only to be a descriptive paper or giving some help to the readers? It is obvious that similar experience can not be replicated and my wish is to read summarized  as final conclusion some specific point of action to improve the end-life assistance and promote this assistance at home. The primary goal of the paper was to describe the trajectory of common physical symptoms among cancer home care patients I would like the Authors make an effort from this huge experience to describe how they suggest to capitalize the amount of collected information. In this way the paper could really teach something to the readers.

Author Response

Thank you for these helpful comments.

In the results, with respect to Fig 1 and 2, we made the direction and increase in symptom prevalence over time more clear.

For the discussion, we elaborated more clearly about the implications of the pain paragraph.

• “This suggests that pain is actually managed well in the home care environment and asking about one’s pain frequency or intensity alone at end of life is insufficient to completely understand the person’s overall pain experience.”

We modified a main paragraph in the discussion to make the take-home points more clear.

• “In contrast, other physical symptoms, like loss of appetite, self-reported poor health, shortness of breath, and a history of falls start at a prevalence of a third of the cohort, and increase steadily until death. To improve care quality, home care providers could use these symptoms as potential harbingers of death, and could initiate palliative care earlier in the disease trajectory. For instance, high health instability has been used as a major predictor of mortality, and markedly increases in the last two months of life, reaching a peak of identifying 50% of the cohort in the week before death. Initiating palliative care services earlier to manage complex symptoms might help to reduce the prevalence of these symptoms and improve patient quality-of-life.”

We have strengthened the conclusion.

• “Because at end of life, many cancer patients are too ill to receive treatment in a cancer center, initiating palliative home care services earlier to manage these complex symptoms is vital to improving quality-of-life and reducing symptom burden for cancer patients at end-of-life.”