Paolo Cotogni

Advances in lung cancer treatment have progressively improved survival across all disease stages. Some patients now achieve long-term survival, while others may remain on treatment for several years, particularly with immune checkpoint inhibitors and selected tyrosine kinase inhibitors. These advances have increased recognition of the survivorship needs of patients with lung cancer, including persistent symptoms, treatment-related toxicities, and social, psychological, and caregiver-related concerns. The integration of palliative care has also become increasingly relevant, reflecting a shift in the traditional care paradigm by extending supportive approaches beyond the end-of-life setting to patients living long-term with active disease. However, evidence and care models addressing lung cancer survivorship remain fragmented and focus predominantly on patients treated with curative intent. This narrative review provides a comprehensive overview of survivorship in lung cancer, from screening and early-stage to locally advanced and metastatic disease, while also examining more cross-cutting physical, psychological and social domains. Greater recognition and systematic assessment of these needs is essential to develop structured, coordinated, and personalized survivorship pathways for the growing and clinically heterogeneous population of individuals living with and beyond lung cancer.

In oncology, body composition (BC) provides clinically meaningful information beyond body mass index, capturing muscle and adipose tissue alterations associated with survival, treatment tolerance, surgical complications and quality of life. Although routine oncologic imaging is widely available, BC assessment remains poorly integrated into daily clinical practice, largely because conventional imaging-based approaches require time-consuming manual analyses, dedicated software and specialized expertise. Artificial intelligence (AI), particularly deep learning-based image segmentation, may automate BC analysis and generate rapid, reproducible, and scalable estimates from routinely acquired imaging, without increasing clinical workload. This opinion paper aims to examine AI-based BC analysis as a potential strategy to integrate BC into routine oncology workflows, outlining its potential clinical benefits and the aspects that need to be addressed before widespread implementation. AI-based BC analysis may improve nutritional assessment, refine clinical and nutritional risk stratification, and help identify patients at increased risk of treatment-related toxicity. In perspective, BC data may also support more personalized nutritional and physical activity interventions and contribute to muscle mass-informed anticancer treatment dosing strategies. Several gaps still limit its clinical implementation, including the need of robust external validation, standardized acquisition and analytical protocols, clinically meaningful cut-offs and ethical, and regulatory and data governance frameworks. AI-based BC analysis is therefore a promising but still evolving approach that may help translate BC from a prognostic marker into a clinically actionable tool in oncology.

Background: The rising prevalence of serious illnesses has increased the demand for emergency department (ED) services. Patients with advanced chronic conditions frequently present to the ED with distressing symptoms. Although symptom prevalence has been well described in oncology populations, fewer studies have assessed non-cancer illnesses, particularly in the ED. This study aimed to compare symptom prevalence in patients with cancer and non-cancer illness awaiting hospitalization after ED admission and referred to the hospital palliative care (PC) team. Methods: We conducted a prospective, observational, cohort study over 2 years [2023–2024] at a tertiary university hospital. Adults with serious illness referred from the ED to the hospital PC team were eligible if they had ≥1 symptom scoring ≥4 in a numeric rating scale (NRS) ranging from 0 to 10. Thirteen symptoms were evaluated, encompassing physical, psychological, and spiritual domains. Prevalence was analyzed descriptively and compared between cancer and non-cancer groups using Fisher’s exact test. Results: Among 542 patients screened, 416 met eligibility criteria: 141 (34%) with cancer and 275 (66%) with non-cancer illness. Nearly all patients reported at least one symptom ≥4. Compared to non-cancer patients, those with cancer more often experienced pain (49% vs. 31%, Pvs. 75%, P=0.02), appetite loss (54% vs. 32%, Pvs. 13%, P=0.02), vomiting (16% vs. 6%, P=0.004), and diarrhea (11% vs. 4%, P=0.01). In contrast, dyspnea was significantly higher in non-cancer illness (62% vs. 35%, PConclusions: This study shows that seriously ill patients presenting to the ED experience substantial symptom burden, but with distinct profiles between cancer and non-cancer conditions. In this sample, pain, fatigue, and gastrointestinal symptoms predominate in cancer, while dyspnea characterizes non-cancer illness. These findings underscore the need for systematic symptom screening and early PC referral in the ED to ensure equitable, timely, and effective symptom relief across all serious illnesses.

Background When dietary intakes are insufficient, oral nutritional supplements (ONS) are valuable allies to ensure effective nutritional care for patients with cancer. ONS benefits in preventing and treating malnutrition, improving clinical outcomes and quality of life and reducing healthcare costs are well supported by the literature. Moreover, the advent of novel ONS formulas, enriched with additional components (eg immune system modulation), might further improve outcomes in patients with cancer. Yet, a critical question remains: why are ONS, under clinical supervision, not fully covered for malnourished patients with cancer as part of their standard care? Objective This narrative review aims to summarise the clinical and economic benefits of ONS in order to analyse the barriers that limit access to clinically supervised ONS for malnourished patients with cancer and their bioethical implications. Methods To address this aspect, we conducted a comprehensive literature search on PubMed, Web of Science and Scopus, including articles published in the last 30 years. Findings Several barriers hinder the full coverage of ONS as part of a supervised clinical plan, including lack of proper healthcare professional training and standardised protocols for nutritional care and fragmented healthcare policies. These obstacles not only negatively affect patient outcomes but also place a significant economic burden on healthcare systems. At a deeper level, this issue also raises bioethical questions. In our society, healthcare aims to preserve life. Nutrition is essential for recovery in cancer, and making its access dependent on patients’ financial capacity, with the risk of failing to provide adequate nutrition, seems to betray this goal. Conclusion Bringing together ethical imperatives, proven clinical benefit and economic rationale, there is strong evidence supporting full coverage of ONS for malnourished patients with cancer.

Background: The impact of home parenteral nutrition (HPN) on the quality of life (QoL) of cancer patients has been previously investigated. However, scarce data are available regarding near-death QoL in patients with cancer receiving HPN. This study aims to investigate the changes of QoL in these patients in the last two months before death. Methods: This is a secondary analysis of a previous, prospective, longitudinal, observational study. QoL was assessed using the EORTC QLQ-C30 questionnaire. Results: Eighty-four adult cancer patients who died on HPN and had filled out the questionnaire between 31 and 60 days (M2) and within 30 days prior (M1) to death were included in this analysis. The questionnaires filled out at M2 and M1 were compared with those filled out by the same patients at HPN start (T0). At M2, there was a significant improvement in both the global QoL and symptoms scales (p < 0.001 and p < 0.033, respectively), while at M1, a significant improvement in the global QoL scale persisted (p < 0.035) compared with T0. Conclusions: Our study first reports that HPN, if started early and according to European guidelines, is associated with an improvement in the QoL of patients with cancer even in the last two months before death.

Purpose of review: Several types of injectable lipid emulsions (ILEs) have become available for parenteral nutrition. The purpose of this review is to highlight the most recent and interesting articles in the field of ILEs. Recent findings: Recent literature has compared ILEs in various clinical scenarios (e.g. abdominal surgery, chronic intestinal failure, critical illness, and preterm birth). Favorable clinical effects of ILEs containing fish oil have been observed in studies on surgical patients with Crohn's disease, critically ill patients, and patients with intestinal failure-associated liver dysfunction, whereas other trials have shown no clear benefit. Ongoing research is focused on finding novel strategies to reduce liver toxicity of ILEs, including the use of ‘artificial intelligence’ tools and liver organoids. Promising new applications for ILEs are emerging, including the prevention of neonatal hypoxic brain injury. Summary: Although ILEs with the goal of reducing the levels of pro-inflammatory omega-6 fatty acids appear to confer some advantage in some settings (e.g. surgery), conclusive data on the superiority of one ILE over another are lacking. In particular, research is needed to compare different types of mixed-oil ILEs with each other and with pure fish oil ILEs.

Radical cystectomy (RC) with pelvic lymph node dissection is the standard treatment for patients with limited-stage muscle-invasive bladder cancer. RC is associated with a complication rate of approximately 50–88%. Immunonutrition (IMN) refers to the administration of substrates, such as omega-3 fatty acids, arginine, glutamine, and nucleotides, that modulate the immune response. IMN has been associated with improved outcomes following surgery for esophagogastric, colorectal and pancreatic cancer. In this paper, we describe a study protocol for a multicentre, randomised, open-label clinical trial to evaluate the effect of IMN in patients undergoing RC for bladder cancer. A 7-day preoperative course of IMN is compared with a standard high-calorie high-protein oral nutritional supplement. The primary outcome of this study is the rate of complications (infectious, wound-related, gastrointestinal, and urinary complications) in the first 30 days after RC. Secondary outcomes include time to recovery of bowel function and postoperative mobilisation, changes in muscle strength and body weight, biochemical modifications, need for blood transfusion, length of stay, readmission rate, and mortality. The results of this study may provide new insights into the impact of IMN on postoperative outcomes after RC and may help improve IMN prescribing based on patient nutritional status parameters.

Social and healthcare professionals often feel ill equipped to effectively engage in difficult conversations with patients, and poor proficiency negatively affects the quality of patient care. Printed educational resources (PERs) that provide guidance on sustaining complex clinical communication may be a source of support if thoughtfully designed. This study aimed to describe the key features of PERs in order to improve the quality of clinical communication according to the perspective of meaningful stakeholders. This was a descriptive secondary analysis of data collected by three remote focus group discussions that involved 15 stakeholders in the context of developing an educational booklet to support professionals in complex communication scenarios. Focus groups were audio-recorded and transcribed verbatim, and an inductive thematic analysis was performed. Three key features of PERs that aim toward quality improvement in clinical communication were identified: (1) having the potential to provide benefits in clinical practice; (2) facilitating, encouraging, and enticing reading; and (3) meeting the need of professionals to improve or update their knowledge. These findings suggest that PERs relevant to professionals’ clinical priorities and learning needs may make their efforts to apply learning in practice more likely and consequently result in improved healthcare quality.

Introduction Up to 83% of oncology patients are affected by cancer-related malnutrition, depending on tumour location and patient age. Parenteral nutrition can be used to manage malnutrition, but there is no clear consensus as to the optimal protein dosage. The objective of this systematic literature review (SLR) was to identify studies on malnourished oncology patients receiving home parenteral nutrition (HPN) where protein or amino acid delivery was reported in g/kg bodyweight/day, and to compare outcomes between patients receiving low (< 1 g/kg bodyweight/day), standard (1–1.5 g/kg/day), and high-protein doses (> 1.5 g/kg/day). Methods Literature searches were performed on 5^th October 2021 in Embase, MEDLINE, and five Cochrane Library and Centre for Reviews and Dissemination databases. Searches were complemented by hand-searching of conference proceedings, a clinical trial registry, and bibliographic reference lists of included studies and relevant SLRs/meta-analyses. Results Nineteen publications were included; sixteen investigated standard protein, two reported low protein, and one included both, but none assessed high-protein doses. Only one randomised controlled trial (RCT) was identified; all other studies were observational studies. The only study to compare two protein doses reported significantly greater weight gain in patients receiving 1.15 g/kg/day than those receiving 0.77 g/kg/day. Conclusion At present, there is insufficient evidence to determine the optimal protein dosage for malnourished oncology patients receiving HPN. Data from non-HPN studies and critically ill patients indicate that high-protein interventions are associated with increased overall survival and quality of life; further studies are needed to establish whether the same applies in malnourished oncology patients.

Health and social care professionals (HCPs) who work in nursing homes (NHs) are increasingly required to sustain serious illness conversations about care goals and preferences. Although these conversations may also be challenging for experienced HCPs and the literature recognizes high-quality communication as key to providing patient-centered care, so far, no specific educational program has been developed for the NH setting to improve HCPs’ communication skills. Our study aims to test the feasibility and potential effectiveness of an innovative, blended communication skills training program (Teach-to-Communicate) targeting the HCPs who work in NHs. This program includes classroom-based theory, experiential learning, and e-learning, and relies on interdisciplinary contexts and several didactic methods. The study consists of two phases: phase I is the development of written resources that employ focus group discussion involving field experts and external feedback from key stakeholders. Phase II consists of a multicenter, pilot, pre-post study with nested qualitative study. The Teach-to-Communicate training program is expected to enhance the quality of communication in NH and HCPs’ confidence in sustaining serious illness conversations, reduce family carers’ psycho-emotional burden and improve their satisfaction with the care received, and increase advance care planning documentation. Our protocol will provide insight for future researchers, healthcare providers, and policymakers and pave the way for blended educational approaches in the field of communication skills training.