bluuebunny/crossref_metadata_2025 huggingface dataset:
Integration of system-level patient-reported outcome measurement into everyday clinical care: Lessons learned from the cancer care Ontario experience.
Authors: Molloy Sean , Pereira Jose , Green Esther , Dudgeon Deborah Jane , Howell Doris , Krzyzanowska Monika K. , Mahase Wenonah , Tabing Reena , Urowitz Sara , Macdougall Laura
Published: February 2017

159

Background: The goal of the collaborative is to improve the quality and consistency of physical and emotional symptom management across the cancer journey. Objectives are to promote the adoption of electronic symptom assessment using a standardized tool and to increase the clinical use of evidence based guidelines to effectively manage patient identified symptoms. Methods: The actions taken for this initiative are (a) manage cancer symptoms through a patient reported measurement tool; (b) improve the quality of symptom management through the uptake of symptom management guides and algorithms for care; and (c) drive improvement through the adoption of an electronic symptom assessment platform. The following aims were established for this work: (1) aim for symptom screening and assessment (70% of ambulatory cancer clinic patients are screened for symptom severity using ESAS at least once/month); (2) aim for symptom management (evidence from chart audits show intervention as per evidence based guidelines for patients reported symptom scores); (3) aim for patient satisfaction (90% of target population indicates that their health care team took their scores into consideration when developing a care plan); and (4)aim for evidence of use (90% of patients state that their doctor or nurse spoke with them about their symptom screen). Results: 60% of cancer patients are screened each month representing over 28,000 people. Six of fourteen cancer regions are above the provincial target of 70%, with some close to 90%. 92% of patients felt ESAS was important to complete to help health care providers know how they are feeling. Conclusions: Cancer Care Ontario has been able to drive improvements in symptom management through the implementation of system wide electronic symptom assessment. For other jurisdictions interested in adopting this approach, the following areas are critical for success: a) leadership at all levels of the system; b) clinical tools at the point of care; c) engagement of patients in the design of care; d) communications support to spread information to all stakeholders; and e) using to data to drive performance improvement and accountability.
Symptom burden, quality of life, and distress in acute myeloid leukemia patients receiving induction chemotherapy: A prospective electronic patient-reported outcomes study.
Authors: LeBlanc Thomas William , Wolf Steven , Davis Debra M. , Samsa Greg , Locke Susan C. , Steinhauser Karen E. , Ubel Peter A. , Tulsky James A. , Abernethy Amy Pickar
Published: February 2017

167

Background: Induction chemotherapy for acute myeloid leukemia (AML) is more intensive than many solid tumor treatments, and may be associated with a different symptom burden. Little is known about the most prevalent symptoms during AML induction, nor how they change over time. Methods: We enrolled AML inpatients at initiation of induction chemotherapy, and assessed their symptoms, quality of life (QoL), and distress weekly during their month-long hospitalization for treatment, using 3 validated instruments: Patient Care Monitor v2.0 (PCM); Functional Assessment of Cancer Therapy–Leukemia (FACT-Leu); and NCCN distress thermometer (DT). Here we report results from the first 16 enrolled patients, using standard descriptive statistics. Results: Mean age of study participants was 59.6 (SD 12.2), and most were newly diagnosed with AML (SD 87.5%, n=14). Patients were mostly high-risk for recurrence, with 50% (8) being >60 years old and 71% (10) having high-risk cytogenetics. Fatigue was the most prevalent symptom, with an average of 59% of patients reporting moderate to severe fatigue at each assessment. The other most prevalent moderate/severe non-functional symptoms were dysgeusia (50%), dry mouth (42%), diarrhea (41%), decreased appetite (37.5%), insomnia (37.5%), daytime sleepiness (36%), nausea (36%), hair loss (36%), and mouth sores (34%). Median QoL by FACT-Leu total score decreased substantially between weeks 1 and 2 (118.5 to 104.5); the most substantial decrements were in subscales for personal well-being and functional well-being (20.5 to 14.5, and 13.5 to 8.5, respectively). QoL did not return to baseline by week 4. Median DT score at baseline was 6.5, with a trend towards weekly improvements in distress (DT = 3 at week 4). Depressive symptoms like hopelessness and sadness were reported by an average of 25% and 31.3% of patients, respectively. Conclusions: AML patients receiving induction chemotherapy have significant symptom burden, impaired QoL, and psychological distress. The prevalence of these issues suggests sizeable unmet palliative care and psychosocial needs in AML patients receiving induction chemotherapy.
Development and validation of a patient-reported tool to evaluate legal and financial needs in patients with advanced cancer.
Authors: Kamal Arif , Bain Richard Morgan , Zafar Yousuf , Uronis Hope Elizabeth , Strickler John H. , Nicolla Jonathan , Goodman Abigail H. , Liu Chrissy
Published: February 2017

174

Background: Cancer patients frequently report problems with finances, housing, advance care planning, and work-related issues. Because of these complex legal needs, cancer centers are developing Medical-Legal Programs (MLP) to connect referred patients with legal professionals. These programs lack validated screening methods to target services to those with the greatest legal distress. To date, no validated, patient-reported measure to assess the portfolio of legal needs has been developed for patients with cancer. Methods: We developed the Cancer Legal Screener to address five common domains within MLP practice: Housing; Income and Insurance; Employment; Family Stability; and Legal Status and General concerns. The 15 questions were then reviewed in two rounds for face validity by two of each: social workers, oncologists, palliative care physicians, attorneys, and lay persons. After two iterative updates, we piloted the screener in our palliative care and gastrointestinal malignancies clinics for six months. After participants completed the screener, they responded to a 10-item survey rating three areas: Consent/Presentation, Ease of Use, and Value to Care. Each question was measured on a 5-point Likert scale. Scores were weighted one through five and averages calculated. Results: We received scores from 79 patients. Their median age was 61 years; 39% were female, 29% were African-American. Regarding socioeconomic status, 75% had completed at least some college and 53% reported having an income level ≤ $50,000. During patient-reported validation testing, all 10 items across the three domains satisfied the feasibility criteria with average weighted satisfaction scores ranging from 3.22-3.89. Of patients surveyed, most indicated “Agree” or “Strongly Agree” regarding understandability of included questions (84%), prompts being “easy to follow” (81%), and “this form may help my doctors deliver better care” (63%). Conclusions: We have developed and validated one of the first patient-reported tools to assess medical-legal needs in patients with cancer. Future research will test triage models to target the appropriate legal resources to patients with the greatest legal needs.
The impact of radiotherapy technique on normal tissue dose in treatment of spinal vertebral metastases.
Authors: Pieters Richard S. , Kuo I-Lin Eric , Bornstein Bruce A , Fitzgerald Thomas J.
Published: February 2017

179

Background: The optimal management of uncomplicated spinal vertebral metastases has yet to be determined. Preliminary evidence, suggesting single fraction therapy may be associated with fewer gastrointestinal side effects, did not report radiotherapy (RT) technique. Recent clinical experience with more advanced imaging and treatment delivery systems leads us to question if this approach is optimal given the radiation therapy dose to the surrounding normal tissues. The purpose of this study is to examine the impact of current RT techniques on normal tissue dose, which is known to affect acute tolerance of sensitive organs. The focus is on the bowel, an organ known for its radio-sensitivity which can impact quality of life. Methods: In a de-identified treatment planning CT of a patient with spinal metastases, the target volume of vertebrae from T9-L5 was defined and the normal bowel was outlined. Five RT techniques were planned: 1) the former standard, posterior/anterior (PA) 6MV field prescribed to a depth of 5 cm, 2) a PA 18MV field prescribed to a depth of 5 cm, 3) an opposed AP/PA dual energy plan, weighted posteriorly 2:1, 4) a 3-field 18MV plan (PA & 2 posterior oblique fields), and 5) an intensity modulated radiotherapy (IMRT) plan, using 4 arcs. The last 3 techniques were optimized to minimize anterior dose to the bowel. Results: The 5 techniques delivered varying RT doses (Dmax%) to the bowel ranging from the highest (AP/PA dual energy plan) to the lowest (IMRT), expressed as a percentage of the prescription dose. Conclusions: Single fraction RT techniques, with the exception of IMRT, approach tolerance (Dmax%) for some bowel tissue, which may preclude retreatment. IMRT would also allow for dose escalation to the spinal target volume, possibly improving efficacy and reducing the need for retreatment. Future studies should report RT technique, dose and fractionation to optimize efficacy and tolerance. [Table: see text]
Relationship of peripheral neuropathy grades with increase of skin perfusion by compression therapy for breast cancer patients.
Authors: Ohno Tsuyoshi , Mine Takashi , Yoshioka Hiroki , Kosaka Mikiko , Matsuda Sadayuki , de Kerckhove Maiko , de Kerckhove Charles , Matsuo Shigetoshi , Azuma Takashi , Sanada Yuichi , Mishima Takehiro , Inoue Satoshi , Hamada Takashi
Published: February 2017

182

Background: Chemotherapy-induced peripheral neuropathy (CIPN) has become a substantial problem because of specific cytotoxic agents such as nab-paclitaxel, oxaliplatin, and eribulin. In addressing CIPN-related side effects caused by nab-PTX, we previously reported better CTCAE v4.0 grades and superior nab-PTX dose maintenance in breast cancer treatment adopting our 3S approach. Our 3S approach combines compression therapy (stockings and sleeves applied 24 hours from the beginning of nab-PTX administration) with medication therapy (selected prophylactic medications goshajinkigan, lafutidine, and mecobalamin applied over the course of treatment). In revisiting how stocking use restored skin perfusion levels decreased by nab-PTX chemotherapy, we examined whether the skin perfusion increases differ by CIPN grade. Methods: Using a laser Doppler blood flow meter with integrated probe (NL-101 Nahri Nexis Japan), we measured the skin perfusion of the lower limbs before and after stocking use across four groups: three groups of 3S prophylactics-treated nab-PTX patients divided by CIPN grade (Grade 0 [G0, n=12], Grade 1 [G1, n=20], Grades 2 and 3 combined [G2+3, n=12]), and one control group of healthy volunteers (GH, n=50). Results: In the control group (GH), the mean increase in skin perfusion level (mL/min/100g) after wearing stockings was 0.90 (SD= 3.36). For the 3S prophylactic treatment patients, the mean increase was 4.25 (4.98) in the G0 group, 2.11 (4.93) in the G1 group, and 2.69 (2.53) in the G2+3 group. ANOVA analysis indicated a significant difference in skin perfusion increase among the groups (p=0.0493). Analysis between the groups indicated significance in the G0 group increase over the control group increase (p=0.0255). Conclusions: CIPN was previously shown to decrease skin perfusion; in the current study skin perfusion responsiveness to stockings differed significantly between chemotherapy patients and healthy volunteers. Restorative skin perfusion increase is potentially related with alleviating CIPN grade, for which further evaluation is needed.
Differences in performance status assessments between palliative care specialists, nurses, and oncologists.
Authors: Kim YuJung , Zhang Yi , Park Ji Chan , Hui David , Chisholm Gary B. , Williams Janet L. , Bruera Eduardo
Published: February 2017

19

Background: The Eastern Cooperative Oncology Group (ECOG) performance status (PS) is one of the most commonly used assessment tools among oncologists and palliative care specialists caring advanced cancer patients. However, the inter-observer difference between the oncologist and palliative care specialist has never been reported. Methods: We retrospectively reviewed the medical records of all patients who were first referred to an outpatient palliative care clinic in 2013 and identified 278 eligible patients. The ECOG PS assessments by palliative care specialists, nurses, and oncologists, and the symptom burden measured by Edmonton Symptom Assessment Scale (ESAS) were analyzed. Results: According to the pairwise comparisons using Sign tests, palliative care specialists rated the ECOG PS grade significantly higher than oncologists (median 0.5 grade, P<0.0001) and nurses also rated significantly higher (median 1.0 grade, P<0.0001). The assessments of palliative care specialists and nurses were not significantly different (P=0.10). Weighted kappa values for inter-observer agreement were 0.26 between palliative care specialists and oncologists, and 0.61 between palliative care specialists and nurses. Palliative care specialists’ assessments showed a moderate correlation with fatigue, dyspnea, anorexia, feeling of well-being, and symptom distress score measured by ESAS. The ECOG PS assessments by all three groups were significantly associated with survival (P<0.001), but the assessments by oncologists could not distinguish survival of patients with PS 2 from 3. Independent predictors of discordance in PS assessments between palliative care specialists and oncologists were the presence of an effective treatment option (odds ratio [OR] 2.39, 95% confidence interval [CI] 1.09-5.23) and poor feeling of well-being (≥4) by ESAS (OR 2.38, 95% CI 1.34-4.21). Conclusions: ECOG PS assessments by the palliative care specialists and nurses were significantly different from the oncologists. Systematic efforts to increase regular interdisciplinary meetings and communications might be crucial to bridge the gap and establish a best care plan for each advanced cancer patients.
Supporting meaningful advance care planning: A quality-improvement initiative to enhance number and preparedness of individuals selected as medical power of attorney.
Authors: Zhukovsky Donna S. , Gaeta Maria Susan , Stepan Karen , Meyer Margaret W.
Published: February 2017

201

Background: Few health care organizations have successfully implemented a systematic process for meaningful advance care planning (ACP). An available and capable medical power of attorney (MPOA) allows early engagement in the process and is a foundation for successful ACP. As a first step, we implemented a quality improvement (QI) initiative to systematically offer patients (pts) an opportunity to select a MPOA that is valid*, incorporating quality measures to better prepare selected individuals for medical decision-making in a manner that supports the patient’s values and goals. Here we report on yield of valid MPOA documents (MPOAD) obtained. Methods: After QI Assessment Board approval was obtained, baseline data were collected for all head and neck medical oncologists (HNMO) over a 2-week period. In cycle 1, electronic health records (EHR) of pts seen by 2 HNMO were screened by clinic RN for MPOA. Those with MPOAD that were not available in EHR underwent RN follow up. All others were referred to social work (SW) for education regarding value of MPOA and factors important to preparation of decision maker. In cycle 2, revisions made to process included limiting targeted pts to new pts and consults (NPC). Results: See Table. Conclusions: Systematic SW contact and counseling increases the yield of valid MPOA, but is still insufficient for optimal results. Additional measures to be evaluated in future cycles include scheduled appointments for all NPC to increase SW contact, tighter follow up after initial SW contact and MD discussion with NPC to indicate importance of selecting a prepared MPOA. [Table: see text]
PROMs from hospital to hospice.
Authors: Teunissen Saskia cornelia , De Graeff Alexander
Published: February 2017

209

Background: Symptom burden in advanced cancer patients (pts) influences quality of life (QoL) and should be leading in advanced care planning for both hospital and hospice populations. The objective is to describe the course of symptomburden in those patients over time. Methods: Symptoms were biweekly assessed with the self-assessment tool Edmonton Symptom Assessment System (ESAS; Dutch translation) in a prospective longitudinal study of hospitalized patients and patients admitted to a hospice. Prevalence and intensity data were entered in a web-based database by distinguishing patients into 3 groups regarding the aim of palliative care: tumor palliation, symptom palliation and terminal care. Results: 808 pts included, mean age 65 (18-93), 57% female; 224 (30%) pts admitted in the hospice-setting, 584 (70%) in a medical oncology ward. The care aimed 36 % tumor palliation, 59% symptom management, 4% terminal care. Most prevalent symptoms were similar in hospital and hospice: fatigue, anorexia, dry mouth, pain, constipation. The highest clinical relevance (score > 4 on NRS 0-10; 0 = no symptom, 10 = worst symptom) was found in hospital for fatigue (56%), anorexia (54%), constipation (48%), dry mouth (44%), pain (33%). In hospice patients fatigue (88%), dry mouth (66%), anorexia (63%), pain (4%), constipation (40%). In both care settings same national guidelines for symptom management are used as bottom line for interventions. 48% hospital patients scored > 4 for overall wellbeing (0= very good, 10 = very bad) vs 68% in hospice. In the hospice cohort pts are discriminated by prognosis, symptomburden, QoL: > 3 months survival, 2 – 12 weeks, < 2 weeks. Analysis is ongoing, data will be presented at the conference. Conclusions: The course of symptom intensity in advanced cancer populations in hospital and hospice setting is quite similar. A combination of general, specialized and expert palliative care competencies are needed during the cancer continuum. Prospective monitoring of patients during the continuum is a methodological and practical challenge.
Oral oncolytics: Patient-monitoring improvements in private practice.
Authors: Mahmood Tallat , Redouty Lindsey , McNamera Elaine
Published: February 2017

215

Background: The use of oral oncolytics is becoming more common. These drugs have their own unique challenges in managing patient initiation, monitoring side effects and adherence. Methods: We conducted a baseline chart audit of patients prescribed oral oncolytics in our private oncology practice followed by a quality improvement program and subsequent reassessment. Information obtained included: prescription date, actual start date and any documented problems with the oral therapy. The baseline audit included patients from may of 2011 to July 2013. Subsequently we joined the Michigan oncology quality consortium’s oral chemotherapy collaborative and initiated the following: office procedures for identification of all patients on oral therapy, use of the Edmonton Symptoms assessment system (ESAS), and a self-care management education program including patient self-monitoring of symptoms with recommended initial treatments. A postintervention audit was conducted from August 2013 to March 2014. Results: We identified 25 patients in the first time period and 13 in the second. In the first time period we found only 13 of the 25 patients had an actual start date documented, and of these 13, 10 had a >/=4 week delay prior to starting therapy, with 3/13 having a 2-4 week delay prior to start of therapy. 12 of the 25 patients discontinued their drug within the first month due to side effects without consulting their physician. After participating in the quality initiative, we identified only one patient without a documented start date, only 1/13 that had a > 4 week delay from prescription date to starting the drug, with 12/13 having a less than 2 week lapse. We also found that there were no patients who discontinued the drug and only one dose reduction as directed by the physician. Conclusions: The introduction of new office procedures to easily identify all patients on oral therapy and improved patient management of symptoms at home with the use of self-care guidelines, and in the office with use of ESAS contributed to greater adherence to oral chemotherapy regimens.
Communicating comfort: How do cancer outpatients and health care providers talk about pain?
Authors: LeBaron Virginia Townsend , Blonquist Traci M. , Beecy Autumn , Berry Donna Lynn
Published: February 2017

229

Background: Pain remains a significant problem for many cancer patients. Poor communication between healthcare providers and patients can contribute to this problem. This secondary analysis explored patient-provider discussions of current pain in the ambulatory oncology setting. Methods: Audio recordings from 66 adult oncology clinic visits in Boston and Seattle were selected from a pre-existing data set of a larger trial. To ensure a diverse sample, all minority recordings (n=33) were selected with a random sample of non-minority recordings (n = 33) matched on patient characteristics. Recordings were reviewed by two independent investigators and each pain discussion was quantitatively coded using 12 variables based on a review of the literature. A pain discussion was defined as any reference to pain or discomfort initiated by either patient or provider. Results: Preliminary analysis of 33 cases revealed 57 separate discussions of pain (6 involved patients denying any pain). Patients and providers were equally likely to initiate discussions about pain (patient initiated total: 27/57; 47%; provider initiated total: 30/57, 53%). Pain discussions overlapped with general symptom assessment, and pain was commonly attributed to effects of oncologic therapy and discussed as stiffness, soreness, or aching, not necessarily as ‘pain.’ Discussions of pain were typically brief and providers asked more close-ended and leading questions (n= 87) versus open-ended questions (n=18) when assessing pain. Providers rarely (n=3) used a validated pain intensity scale (e.g., 0-10) and explored reports of pain slightly more often than acknowledging only (n=27/51; 53%; n=24/51; 47%, respectively). Conclusions: Discussions of cancer related pain in the ambulatory setting are complex, often with multiple reports of pain of varying etiologies discussed throughout the clinic visit. Providers may limit communication by asking mainly close-ended questions and only exploring patient's pain reports about half the time. This analysis offers insights into areas for improvement in communication patterns related to cancer pain.
Psycho-oncology via telemedicine: A model to provide services to a rural population.
Authors: Krigel Susan , Nelson Eve-Lynn , Spaulding Ashley , Krebill Hope , Leepers Melanie , Doolittle Gary C.
Published: February 2017

236

Background: The Midwest Cancer Alliance (MCA), the outreach arm of the University of Kansas Cancer Center, developed psycho-oncology services over videoconferencing in partnership with its rural members. The collaborative goal is to address patient-identified psychosocial needs that are not currently being met in the communities. Methods: Following telemental health best practices, MCA personnel, rural site leaders, local oncology and behavioral health teams, and telemedicine staff collaborated closely to establish the service. They developed detailed protocols related to: referral and scheduling; technical training and support; paperwork; videoconferencing sessions; post-visit follow-up/documentation; and emergency management procedures. Attention was given to: confidential space; equipment to meet therapy needs; the telemedicine coordinator’s role; and completion of professional requirements (e.g., licensing, credentialing, malpractice coverage). Results: Credentialing, site implementation, and patient recruitment took longer than anticipated. To date, 15 patient visits have occurred through the psycho-oncology service across two rural sites. Worsening illness has impacted referrals as well as retention in therapy. Videoconferencing services have approximated onsite psycho-oncology strategies, with focus on evidence-based care. In general, patients have had advanced medical illness as well as significant premorbid psychosocial difficulties, such as mood disorders, substance abuse history, and relationship problems. Basic challenges to care have remained, including lack of consistent transportation. The telepsychologist’s role in relation to the rural medical team expectations is still evolving. Conclusions: The early lessons learned will continue to strengthen the psycho-oncology service as videoconferencing services expand in order to increase access. Ongoing, site-specific needs assessment remains essential, as “one size does not fit all.” Future plans include improving recruitment by coordinating referrals with distress screening. In order to provide sites with maximum flexibility, new methods of communication will be offered as they become available.
Change in symptom burden within one day of palliative care consultation in a cohort of gynecologic oncology inpatients.
Authors: Lefkowits Carolyn , Teuteberg Winifred , Courtney-Brooks Madeleine , Sukumvanich Paniti , Kelley Joseph L.
Published: February 2017

28

Background: Change in symptom burden after inpatient palliative care consultation for symptom management in gynecologic oncology patients has not been described. Our objective was to evaluate the magnitude and time course of change in symptom burden after palliative care (PC) consultation in a cohort of gynecologic oncology inpatients. Methods: Women with a gynecologic malignancy and a PC consultation for symptom management between 3/1/12 and 2/28/13 were identified. Charts were reviewed for demographics and disease characteristics. PC provider reports of patient symptom intensity on a modified Edmonton Symptom Assessment System were retrospectively reviewed. Data was analyzed with descriptive statistics and two sample test of proportions to compare prevalence of moderate to severe symptom intensity on the day of consultation to the day after consultation. Results: Over 12 months, there were 172 PC consultations for symptom management involving 123 unique patients. The median age was 58 and most common cancer was ovarian (44%), followed by cervical (26%) and uterine (24%). Prevalence of moderate to severe symptoms on the day of consultation is outlined below. There were statistically significant decreases in prevalence of moderate to severe symptom intensity within one day of PC consultation for pain, anorexia, fatigue and shortness of breath (SOB) (see table). Conclusions: PC consultation is associated with significant improvements in symptoms within one day of consultation. Palliative care consultation may be an effective tool for symptom management during even very short hospitalizations and should be considered early in the hospitalization to effect timely symptom relief. [Table: see text]
Parent distress related to child health outcomes during hematopoietic stem cell transplant (HSCT).
Authors: Ullrich Christina Kathleen , Rodday Angie Mae , Parsons Susan Kenyon
Published: February 2017

31

Background: HSCT offers possible cure yet remains intensive and high risk. Parent distress related to potential child outcomes during HSCT is unexplored. Methods: Parents of children undergoing HSCT (n=363) at 8 US transplant centers completed the Child Health Ratings Inventories (CHRIs) measuring parent and child general health and QOL at baseline (BL) through 12 mos post HSCT. Main outcomes: responses to 2 CHRIs items regarding parent worry about child "health worse" and "might die," rated on a 5-point Likert scale ranging from none to all of the time, and transformed to 1-100 (higher, more worry). Analyses focus on BL to D45 when parent worry decrease was pronounced. Clinical data were abstracted from charts. BL personal, clinical and HSCT course characteristics with p<0.2 on univariate analysis were entered into multivariable models adjusting for transplant center, then eliminated by backward selection (p<0.1). Results: Parents were 83% female, 77% White, median age 38.7 yr (IQR 33-44). Child median age was 9.6 yr (IQR 6-14). Most (72%) had cancer; 78% underwent allogeneic HSCT. By D45, 33% had systemic infection, 33% acute graft versus host disease (aGVHD) and 20% intermediate/poor Bearman toxicity score. Mean parent "might die" worry decreased from BL (41.9, SD 8.3) to D45 (26.6, SD 24.6) (p<0.001). "Health worse" worry similarly decreased. Despite this, ongoing worry risk factors exist including younger child age, solid tumor and hematologic malignancy but not HSCT course characteristics (Table). Conclusions: Some parents remain at risk for unmitigated distress about child health, largely irrespective of the HSCT course. Enhanced supports such as palliative care consultation may be of benefit. [Table: see text]
Return-to-work issues in outpatient palliative care.
Authors: Glare Paul A. , Nikolova Tanya , Alickaj Alberta , Blinder Victoria Susana , Patil Sujata
Published: February 2017

35

Background: Early integration of palliative care (PC) with oncologic care means return to work (RTW) issues will apply to some patients. There is an extensive literature on RTW after completing definitive treatment but much less is known about RTW in patients with active disease and on treatment. Methods: Cross-sectional survey of patients in two Pain & Palliative Care (PC) clinics at a comprehensive cancer center. Respondents were aged 25-65 and had been in paid employment prior to or during their treatment. The survey consisted of 37 items covering three domains: clinical details and demographics; work status, occupation, and work ability; importance of work and factors interfering with work. Results: 105 surveys were completed. 54% respondents were females, median age 53. 79% had been working at the time diagnosis. The commonest primaries were breast, colorectal, lung, GYN, and melanoma/sarcoma. 80% reported having active disease, median 2 years since diagnosis, and 73% were currently on treatment. In patients with active disease (n=86), 47% were currently working, 63% of them full time, typically RTW after taking < 6 months off. Work was important to 80% them, making 83% "feel normal", and 58% feel like they are “beating the cancer”. 35% would have liked to work more hours. Fatigue interfered with work in 49%, pain in 38%, and side effects of pain medicines in 31%. Almost ¼ were anxious or depressed about their work situation. More than 20% experienced discrimination in the work place, although usually minor. Conclusions: It is not uncommon for patients with advanced cancer to RTW even when they are on treatment and are sick enough to need to be followed in a PC clinic. Work is important to them and many would like to work more. Symptoms and side effects may interfere with their work ability. Some may be experiencing discrimination in the work place. Interventions to overcome these problems should be part of comprehensive, interdisciplinary PC.
Randomized trial of high- versus low-intensity breathing training for dyspnea due to intrathoracic cancer: Cost-effectiveness.
Authors: Johnson Miriam , Kanaan Mona , Richardson Gerry , Nabb Sam , Barton Rachael , Torgerson David , Booth Sara
Published: February 2017

54

Background: About 90% of patients with lung cancer experience dyspnea. Breathing training is helpful, but multiple sessions may be onerous. Methods: UK multisite phase 3 RCT, comparing three weekly sessions of breathing training to a single session for refractory dyspnea due to intrathoracic cancer. Primary outcome: self-report “worst” dyspnea/24 hours, (0–10 numerical rating scale [NRS], 0=none; 10=worst imaginable). Secondary outcomes: “average”, distress due to dyspnea (NRS); quality of life (QoL) (CRQ-SAS; EQ-5D); health service utilisation. Primary analysis point: 4 weeks for dyspnea/QoL. An economic analysis addressed cost-effectiveness from the perspective of UK National Health Service (NHS) and personal social services in a budget constrained system; costs at NHS 2012/13 prices. Primary outcome: Quality Adjusted Life Year (QALY) over 8 weeks. Results: 156 were randomized: age 69 (SD 9.4); 40% women; Karnofsky performance status 71% (SD 9.5); 133 primary lung. “Worst” score improved, 6.8 (SD1.9) at baseline to 5.8 (SD 2.4) at week 4. There was no detected difference in area under curve (AUC): three 22.9(SD 7.1) versus single 22.7(SD 7.1); P = 0.83; 95% difference CI (-2.3, 2.9), or for AUC “average”, or CRQ-SAS. AUC “distress” was less in the single group (16.2 versus 12.3; P = 0.01). Using complete cases, three sessions were associated with a QALY reduction of 0.006 (95% CI -0.18 to +0.006) over 8 weeks and 0.008 (95% CI -0.022 to 0.006) with multiple imputation, and showed increase in costs when adjusted for baseline health related QoL (Mean increased cost £37; 95% CI -506 to +581). Conclusions: Three sessions conferred no benefits over one and had a worse QALY profile. Though statistically insignificant, a single session seems to be a cost-effective way to provide breathing training, minimising the burden of healthcare visits. Clinical trial information: ISRCTN49387307.
Challenging conversations in oncology: A workshop for fellows.
Authors: Ramchandran Kavitha , Schapira Lidia , Spiegel David , Harman Stephanie , Fronk Joshua , Kogon Manuela , Kostopoulos Kay , Tribett Erika L , Berek Jonathan S.
Published: February 2017

60

Background: Compassionate communication is critical to patient-centered cancer care. Conversations about sensitive topics are necessary to help patients make well-informed decisions. Still, many oncologists feel ill-equipped during these conversations and thus avoid them or approach them with a purely clinical perspective. Fortunately, empathic communication skills can be learned. This project, Challenging Conversations in Oncology (CCO), involves the development of an experiential workshop to help build skill and confidence communicating with cancer patients. The workshop is part of a movement to reimagine cancer care at Stanford. Methods: The first iteration of CCO was multi-day event with didactic lectures, self-awareness exercises and small group role-play. The faculty was multi-disciplinary, including clinicians in various subspecialties, communications experts and patients themselves. Activities were designed to build skills in interviewing, cultural humility, adapting communications, and dealing with patient and provider emotions. A post-workshop evaluation survey assessed overall effectiveness as well as self-reported learning and perceived enhancement of patient care as a result of participation. Results: The CCO workshop was implemented in Fall 2013. Participants included 17 physicians from various oncology subspecialties. Participants reported that the workshop was very valuable (rating at least 4 on a 5-point scale of overall effectiveness). Common themes included learning to “slow down” and do “less talking, more listening,” taking time to “let patients express themselves…cry, be silent.” Faculty reported enthusiasm watching trainee communication skills “evolve along with…the patient’s story.” Conclusions: This workshop was a significant educational opportunity for junior faculty at Stanford. Feedback suggests the experience was rewarding and influential. It encouraged cultivation of communication skills that will likely benefit doctors and their patients. This fall (Year 2), we will extend this workshop to senior faculty, staff, and administration. The course will continue to evolve to meet the needs of providers and align with comprehensive institutional enhancements in cancer care.
Advance-care planning quality improvement plan: A Cancer Care Ontario toolkit to support primary care teams to implement advance care plans in practice.
Authors: Myers Jeff , Strasberg Suzanne , Carroll Kathi , Dhanji Zabin , Harle Ingrid , Urowitz Sara , Walton Tara , Zwicker Victoria
Published: February 2017

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Background: In Ontario, the Ministry of Health and Long Term Care’s (MOHLTC) uses Quality Improvement Plans (QIPs) to drive system improvement aimed at providing high value, high quality care for all. To support the introduction of QIPs into the primary care sector, Cancer Care Ontario has developed an Advance Care Planning (ACP) toolkit for practices that include ACP as part of their annual QIP. ACP is an ongoing and dynamic process that involves a capable individual reflecting on their current values and beliefs for their health care, communicating their personal wishes for future health care and identifying an individual who will make decisions on their behalf in the event that they are unable to provide informed consent. The process is iterative and wishes may change over time with changes in health status. Methods: The ACP QIP was developed based on the Plan, Do, Study, Act cycle of continuous quality improvement. The ACP QIP provides primary care practices with detailed instructions on how to implement, monitor and report on an ACP Quality Improvement initiative. Importantly, the ACP QIP provides guidance and practical tools for developing objectives, establishing targets, and identifying measures and baselines for performance. CCO is actively promoting the ACP QIP in an effort to encourage uptake and broad adoption across Ontario. Results: There is now evidence that with ACP there is a greater likelihood EOL wishes will be both known and followed resulting in improved EOL care. ACP is also associated with decreased distress among the family members. Conclusions: Creating an ACP QIP supports primary care’s focus on advancing quality patient care. Importantly, implementing the ACP QIP into primary care practices has the potential to improve EOL care and secondarily reduce health care costs ultimately working towards achieving the triple aim of “better care, better health, and lower costs”.
Care, quality, and cost implications of the timing of palliative care consultation among patients with advanced cancer.
Authors: Scibetta Colin , Rabow Michael W. , Kerr Kathleen
Published: February 2017

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Background: ASCO recommends that early palliative care (PC) be offered alongside standard cancer care for patients with metastatic cancer and/or high symptom burden. There is limited data about how the timing of PC affects the quality, intensity, and cost of care at the end of life for patients with advanced cancer. Methods: We analyzed administrative and billing data to assess patterns of healthcare utilization for a cohort of patients at an academic comprehensive cancer center who died from cancer between Jan 1, 2010 and May 31, 2012. We examined the associations of early PC (>90 days prior to death) versus late PC (<90 days prior to death) with QOPI, NQF, and other established quality metrics and direct cost of medical care in last 6 months of life. Results: Among 978 decedents who received treatment at the cancer center, only 298 (30%) had specialty PC referrals. Of these patients, 94 (9.6% of decedents, 31.5% of referrals) had early PC while 204 (21% of decedents, 68.5% of referrals) had late PC. Patients who received early PC had a lower rate of inpatient admissions in the last month of life (33% vs. 66%, p=0.002), lower rates of ICU stay in last month of life (5% vs. 20%, p=0.0005), fewer ED visits in last month (34% vs. 54%, p=0.0002), fewer instances of hospice length of service <3 days (7% vs. 20%, p=0.0001), and a lower rate of inpatient death (15% vs. 34%, p=0.0001). Most patients (84%) who received early PC were seen as outpatients, while late PC was mostly delivered in the hospital (82.4%). Of the late PC cohort, only 52 (25.4%) were ever seen in the outpatient PC clinic, but 170 (83%) had at least one oncology office visit 91-180 days prior to death. The direct cost of inpatient medical care in the last 6 months of life for patients with early PC was reduced when compared to patients who had late PC ($19k vs. $25.7k), while the direct cost of outpatient care was higher in the early PC compared to late PC population ($13k vs. $11.5k). Conclusions: Early PC is associated with less intensive medical care and improved quality outcomes at the EOL for patients with advanced cancer. Early PC results in a significant inpatient cost savings with a modest increase in outpatient costs. Early PC is likely best delivered in the outpatient setting.
Physicians' perceptions of palliative care.
Authors: Gidwani Risha , Meier Diane E. , Asch Steven M , Kirch Rebecca A
Published: February 2017

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Background: Physicians are often gatekeepers to palliative care for their patients. Physicians’ attitudes and beliefs regarding palliative care will therefore influence patient receipt of these services. Here, we explored physicians’ perceptions of palliative care. Methods: We conducted a focus group with 2 hospitalists and 3 medical oncologists. We asked physicians to define palliative care and elicited their suggestions regarding best way to communicate the role of palliative care to patients as well as to other physicians. Results: Physicians generally defined palliative care as comfort care, with two physicians denoting palliative care as occurring during the end of life. Focus group participants felt the best way to communicate the role of palliative care to other physicians was to denote its ability to support physicians in their work by helping coordinate patient care, managing complex physical and emotional symptoms, devoting time to intensive family meetings, and resolving conflicts between patients/families and physicians concerning goals of care, do-not-resuscitate orders, and treatment requests. They disagreed that palliative care should be integrated at all points in a patient’s disease trajectory. Conclusions: Physicians had generally positive reactions to palliative care. Palliative care is often associated with end-of-life care. Further research and exchange about the appropriate timing of palliative care is needed.
Characterizing the specialty palliative care workforce in the United States: Results of a national survey.
Authors: Kamal Arif , Bull Janet , Rogers Ursula A. , Swetz Keith Mark , Kavalieratos Dio , Abernethy Amy Pickar
Published: February 2017

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Background: Increasingly, oncology teams and specialty palliative care (PC) clinicians are collaborating in the care of patients with serious or advanced cancer. Because of such partnerships, PC services have grown tremendously, with teams now available in most US cancer centers. Despite increased penetrance of services, little is known about the workforce that delivers this care, including their demographics, training, and future plans. Methods: Members of the American Academy of Hospice and Palliative Medicine (e.g. advanced practice provider (APP), registered nurses, chaplains) completed a workforce characteristics survey through electronic invitation in the second half of 2013; respondents were recruited via e-mail, blog and Facebook posts, and Twitter tweets. Descriptive statistics were calculated. Results: 1,241 clinicians responded, representing approximately a third of those who received the survey; 68% were physicians and 14% were APPs. Most (56%) were older than 50 years of age; 65% were female. Of physicians, 58% were board-certified through the experiential track, while 22% had completed fellowship training. Of clinical responsibilities, about half (48%) split time between consultative PC and hospice; 30% performed PC consultations only. Regarding organization size, 35% work with 1-3 other colleagues; 8% work alone. Regarding tenure, 34% have worked in PC for <5 years; 22% for >10 years. 82% reported they would become a PC clinician again, if asked to revisit their career choice. Of motivations for joining clinical PC, leading reasons were “opportunity for personal growth” and “influential experience during practicing another specialty”. About half (47%) intend to leave the field within 10 years. Of reasons to leave, 49% will retire; 24% may leave due to burnout; and 20% reported dissatisfaction with practice. Conclusions: The specialty PC workforce is diverse and faces sustainability challenges due to advancing physician age, impending retirements, evolving burnout, and dissatisfaction with the profession. If patients are going to have adequate access to services, research and approaches are needed to develop solutions that sustain and grow specialty PC.
Utility of the proximal margin frozen section for resection of gastric adenocarcinoma: A 7-institution study of the U.S. gastric cancer collaborative.
Authors: Squires Malcolm Hart , Kooby David A. , Pawlik Timothy M. , Weber Sharon M. , Poultsides George A. , Schmidt Carl Richard , Votanopoulos Konstantinos I. , Fields Ryan C. , Ejaz Aslam , Acher Alexandra W. , Worhunsky David J. , Saunders Neil , Swords Doug S. , Jin Linda X. , Cho Clifford Suhyun , Bloomston Mark , Winslow Emily , Cardona Kenneth , Staley Charles A. , Maithel Shishir K.
Published: February 2017

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Background: The proximal gastric margin dictates the extent of resection for gastric adenocarcinoma (GAC). The value of achieving negative margins by additional gastric resection after a positive proximal margin frozen section (FS) is unknown. Methods: The US Gastric Cancer Collaborative includes all patients who had resection of GAC at 7 institutions by oncologic surgeons from 2000-2012. Intraoperative proximal margin FS data were classified as R0 or R1 based on final permanent section (PS); positive distal margins were excluded. Primary aim was to evaluate the impact on local recurrence (LR) of converting a positive proximal margin FS to an R0 final margin by additional resection. Secondary endpoints were recurrence-free (RFS) and overall survival (OS). Results: Of 860 pts, 520 had a proximal margin FS; 67 were positive. Of these 67, 48 were converted to R0 on PS by additional resection. R0 proximal margin was achieved in 447 pts (86%), R1 in 25 (5%), and R1 converted to R0 in 48 (9%). Median FU was 44 mos. Although LR was decreased in the converted R1 to R0 group compared to the R1 group (10% vs 32%, p=0.01), when accounting for other pathologic variables on multivariate (MV) analysis, R1 to R0 conversion was not associated with decreased LR. Median RFS was similar between the R1 to R0 and R1 cohort (37 vs 31 mos; p=0.6) compared to 110 mos for the R0 group. Median OS was similar between the R1 to R0 conversion and R1 groups (36 vs 26 mos; p=0.14) compared to 50 mos for the R0 group. On MV analysis, increasing T-stage and positive lymph nodes were associated with worse OS; R1 to R0 conversion of the proximal margin was not associated with improved OS (p=0.5; Table). Conclusions: Conversion of a positive intraoperative proximal margin frozen section during gastric cancer resection does not decrease local recurrence or improve recurrence-free or overall survival. This may guide decisions regarding the extent of resection. [Table: see text]