bluuebunny/crossref_metadata_2025 huggingface dataset:
Treatment of bone metastases in a rural setting: The effect of Choosing Wisely.
Authors: Lovett Richard Dana
Published: February 2017

133

Background: In 2013, the American Society of Therapeutic Radiology released its list of Choosing Wisely Initiatives. One of these initiatives was to use fraction schemes which may allow less than 10 fractions for the palliation of bony metastatic disease. Such schemes may use one or five fractions to treat an uncomplicated case of bone metastases. This project looks at a rural radiation practice, both before and after a decision was made to employ the Choosing Wisely guidelines when appropriate. Methods: This is a non-randomized, retrospective analysis of 12 months of bone metastases treatments in a single provider practice comparing the 6 months before Choosing Wisely adoption to the 6 months after. A total of 37 consecutive patients, 63 treatment sites were examined. Comparing to a standard 10 fractions of 300 cGy, fifteen treatment fractions were eliminated before adoption, 84 treatment fractions were saved after the guidelines were published. Results: Because of the bias of the practitioner, 14% of the patients received shorter fraction schedules before the Choosing Wisely adoption, 68% of patients after. As far as radiation treatment charges, $12,000 in treatments were saved before adoption, $69,000 in treatments were saved after. Besides the cost savings for the treatments, there were benefits to the patient and to the caregivers. The average patient receiving a shortened fraction schedule saved 145 miles of commuting during the course of their treatment, and saved 5 hours of commuting and treatment time. Assuming that caregivers were employed, a caregiver bringing a patient in for their treatment saved $170.00 in lost wages during the commuting and treatment time. One patient was hospitalized for her treatment and her hospital stay was reduced by the altered fractionation. No patient in the study required retreatment, the minimum follow up period was 6 months. Conclusions: Shorter fraction schemes when used as clinically appropriate do offer savings, not only to health care payers, but also to patients and to patients’ families. Consideration of Choosing Wisely Initiatives has saved patients time and expense as opposed to a similar time period before the initiative. With patients with pain from metastases, these savings are significant.
Predictors of early referral of advanced cancer patients to an outpatient palliative care specialty clinic in a tertiary cancer hospital.
Authors: Dalal Shalini , Dev Rony , Tanco Kimberson , Williams Janet L. , Bruera Eduardo
Published: February 2017

136

Background: Integration of palliative care (PC) with oncologic care has been advocated. In recent years our group has observed increased referral of cancer patient in earlier stages of illness. Our study objective was to compare clinical characteristics of advanced cancer (aCA) patients referred by their oncologists within 2 months of aCA diagnosis (early referral, ER) versus those referred more than 2 months later (late referral, LR). Methods: We collected data on baseline characteristics, symptoms, and the timing of PC referral on consecutive cancer patients seen in first consultation at the outpatient PC specialty clinic in fiscal year 2013. Results: Of the 1225 cancer patients referred for PC consultation, 968 (79%) patients had aCA, of which 38% (n = 372) were seen as ER, and 62% (n = 596) as LR. As compared to the LR group, patients in the ER group had significantly higher severity of pain, SOB, anxiety and drowsiness. In the ER group, a significantly higher proportion of patients had aCA status at initial presentation to their oncologist as compared to the LR group (83% versus 60%; p < 0.0001). Of all the referring primary services, Thoracic Medicine was the only service where a majority of aCA patients were in the ER group (161 versus 122 patients; p < 0.05). In regression analysis, the odds of patients being referred early was higher if they belonged to the Thoracic Medicine service, had aCA at initial presentation to their oncologist, and had higher severity of fatigue and drowsiness. Overall, the median survival of aCA patients, calculated from date of PC consultation, was 5.9 months, and did not differ between ER and LR groups (6.1 and 5.8 months; log-rank 0.832). Conclusions: Our study demonstrates that oncologist’s decision to refer patients early to PC clinic depends on the type of primary service, having advanced stage disease at initial presentation, presence of symptoms of fatigue and drowsiness, and prognostication of decreased survival. The median survival time of 6 months from PC consultation is encouraging and suggests earlier PC referral of cancer patients as compared to earlier reports.
Impact of integrated palliative care model on end-of-life (EOL) quality metrics for patients with kidney cancer (RCC) and melanoma (M).
Authors: Lynch Jessica A. , DeSanto-Madeya Susan , Zerillo Jessica A. , Gregas Matt , McDermott David F. , Mukamal Kenneth J. , Buss Mary K.
Published: February 2017

137

Background: Early palliative care (PC) improves quality of life (QOL) and enhances end-of-life (EOL) care, but the optimal timing and most effective model for integrating PC into oncologic care is uncertain. To understand the impact of an integrated model with PC providers embedded with oncologists vs. usual care (UC) with referral at the discretion of the same oncologists, we examined the timing and delivery of PC and Quality Oncology Practice Initiative (QPOI) EOL metrics among patients with RCC and M in a single clinic. We hypothesized that integrated PC would result in more referrals, earlier contact with PC and better QOPI EOL metrics compared with UC. Methods: In a retrospective cohort study of patients with RCC and M in the Beth Israel Deaconess Biologics Clinic who expired between 10/1/12 and 12/31/14, we compared patients seen 2 days/week, when referral to PC was discretionary, with a third day when PC providers shared the clinic for real-time consultations. Patients were identified as meeting PC eligibility if they had recurrent, metastatic disease and were on active treatment or had a symptom severity of 7+ on Edmonton Symptom Assessment Scale (ESAS). Two oncologists saw all patients, regardless of day. Results: Seventy-six patients expired, 19 in the Integrated PC model and 57 with UC. Patients were similar with respect to diagnosis and demographics except for smoking. The integrated model substantially improved timing and location of PC. In the integrated PC model, 85% were seen by PC compared with 45% in UC (P = 0.002). All patients in the integrated model began PC as an outpatient compared with 36% in UC (P < 0.001). The mean number of days from first PC contact to death was 28 (SD = 54) for UC and 118 (SD = 120) with integrated PC (P < 0.001). The location of death did not differ significantly between models, occurring outside the hospital with hospice among 71% of patients in the integrated model and 53% in UC (P = 0.25). Results were similar in relative risk models adjusted for smoking. Conclusions: A practice model that integrated PC with oncologic care was associated with more PC referrals, earlier contact, and a nonsignificant trend toward fewer deaths in hospital and ICU.
Analysis of patient care in a “Palliative Medicine Day Care Unit” in a hospital in Costa Rica during its first year.
Authors: Cartin Andrea , Benavides Rosaura , Zeledon Manuel
Published: February 2017

140

Background: A “Palliative Medicine Day Care Unit” (PMDCU) program began in January of 2014 as part of the services provided by the Department of Palliative Medicine in a national hospital in Costa Rica; the program allows patients with hemato-oncological diseases to continue as outpatients while receiving inpatient treatment for their refractory symptoms. This study analyses patient consult rates, results and the dynamics of the unit during its first year in service. Methods: The statistical information of patients attended in the PMDCU, were collected during the period between January and December of 2014. The data included: the population characteristics, the nature of the care provided and the interaction with other departments. Results: A total of 1311 patients were examined in the PMDCU, for a total of 1609 consultations; on average each patient had 3.6 consultations. The average time patients spent with physicians during consultation or receiving treatment were 115 minutes. The most common patient diagnosis was gastrointestinal, gynecological, and prostate cancers. After the initial consult, 63% of patients continued treatment in the outpatient clinic of the same hospital, 34% were scheduled for follow-up consultations in the PMDCU, 2.4% of patients were referred to the Emergency Department and less than 2% of patients were either admitted to the hospital or were referred to other palliative care units. Treatment in the PMDCU included, analgesia treatment administration, paracentesis, thoracocentesis, parenteral nutrition, blood transfusions and patient and family education. Conclusions: The PMDCU has had acceptance among patients with a high number of consultations and adequate follow up of patients. The most common types of cancer diagnosis were gastrointestinal, gynecological and prostate cancers. The majority of patients examined, continued treatment in either the outpatient clinic or follow up in the PMDCU; few were referred to the emergency department. The PMDCU provides treatment that would normally be administered either in an inpatient setting or in the emergency department, but avoiding the extra cost and inconvenience to the patients and their family.
Measuring implementation of early, concurrent palliative care in community settings.
Authors: Bakitas Marie , Dionne-Odom J Nicholas , Pisu Maria , Babu Dilip Sankar , Smith Tasha , Akyar Imatullah , Zubkoff Lisa
Published: February 2017

145

Background: ASCO recommends “…combined standard oncology and palliative care…early in the course of illness for any patient with metastatic cancer and/or high symptom burden”. Few settings have implemented this recommendation and rural community cancer centers (CCC) are particularly disadvantaged due to scarce palliative care (PC) resources. The evidenced-based ENABLE (Educate, Nurture, Advise, Before Life Ends) early concurrent PC intervention has demonstrated efficacy and benefit for rural patients and caregivers and we are implementing ENABLE using a virtual learning collaborative funded by the American Cancer Society. Since no PC-specific implementation measures exist, one of our primary efforts has been instrument development. Methods: This Implementation Study includes 4 racially-diverse CCCs: Gibbs Cancer Center, Spartanburg, SC; Mitchell Cancer Institute, Mobile, AL; Birmingham VAMC; and Gyn Oncology/University of Alabama at Birmingham. The project aims are to: 1. Build an interactive research community to assess sites’ institutional structure and PC resources; and 2. Evaluate pre- and post-ENABLE implementation using RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. An expert panel assisted with implementation measure development specific to ENABLE’s essential elements. Instruments include: the General Organizational Index, the RE-AIM Assessment Tool, Oncology Providers Perceptions of Early Concurrent PC, and Implementation Costs. Results: All measures were found to have face and content validity. Feasibility and inter-rater reliability were determined during pilot-testing. Data, (housed in a REDCap database), have been collected using face-to-face interviews and web-based platforms over 2 cycles of pre- and post-implementation site visits. Measurement challenges include: 1. Inconsistent IRB interpretation of implementation science practices; 2. Limited implementation resources (space, staff, and time); and 3. Difficulties with centralized data collection. Conclusions: Valid measures are critical to determine implementation success. We will present implementation measures (Toolkit) and examples of outcome data.
Beyond the pilot: Navigating through 8 years of palliative radiotherapy integrated symptom management (PRISM).
Authors: Huang Fleur , LeGuerrier Bronwen , Severin Diane , Eberle Shannon , Chu Karen P , Gagnon Lori , Fairchild Alysa
Published: February 2017

156

Background: Patients with incurable cancer often have problematic symptoms and functional impairment despite active cancer care. Opportunities to assess and address these unmet needs exist at every care point. Methods: In 2007, we piloted a holistic model of care in an outpatient Palliative Radiation Oncology clinic. Twin goals (timely access to radiotherapy (RT) and multidisciplinary (MDT) symptom assessment/management) were met: a one-stop-shop to see a radiation oncologist (RO), nurse (RN), radiation therapist (MRT(T)) and pharmacist, with Social Work, Nutrition and Rehabilitation as needed. The model has since evolved, adapting to shifting system-level barriers, with continued attention to patient-reported outcomes. We discuss our team’s 8-year effort to integrate symptom management and palliative RT in a tertiary cancer center. Results: Despite challenges (patient-, provider-, facility-, service- or logistics-related), our target RT population grew from initially only those with bone metastases (served by 1 RO once weekly), to include brain or chest disease (seeing any local RO, any day). Priorities were complex, even at odds, to cater to broadly defined stakeholders: access to RT, systematic basic supportive care (BSC), operational efficiency, care transitions. From strong interdisciplinary focus and task-shifting emerged a critical patient navigation piece. Informal, then formal quality improvement work recast key functions by person/time/place, recently streamlining (e.g. intake/triage/referral pathways) and upgrading (e.g. shared RN/MRT(T) navigator role). Interfaces are layered, broad now between BSC (e.g. horizontal pre-/post-visit telephone symptom screening and goal-setting) and RT processes (e.g. more consistently vertical, less disruptive to technical workflows), enabling scale-up and alignment by design with quality dimensions. Operational and patient outcome metrics remain under periodic review. Conclusions: Integrating MDT BSC with outpatient palliative RT is feasible and scalable, when incrementally tailored to context. Further work, to formally assess patient satisfaction and downstream care needs, will inform PRISM as our local standard.
Embedded integration of palliative care in an academic outpatient cancer center.
Authors: Sinclair Christian T
Published: February 2017

158

Background: Palliative care is no longer reserved for ICUs and inpatient settings, since it can be delivered at any age and any stage regardless of goals of care. Oncologists are beginning to embrace more upstream palliative care but translating that to the long term setting has unique difficulties. Outpatient palliative care is a vital component to quality oncology care, but few examples of successful integration have been demonstrated. Methods: Data was collected from the palliative care clinic at the University of Kansas Medical Center Westwood Cancer Center. Descriptive analysis of the initial and current programs as well as successful outreach and education projects will be discussed. Quantitative analysis of number of initial and follow-up outpatient visits, cancer type, referring service and referring physician are all included. Hospice utilization was also recorded as well as length of time from initial consult to either death, discharge or calendar date June 30, 2015. Results: Since the pilot clinical program of outpatient palliative care in 2012 with two half day clinic sessions focused on BMT patients, the program has expanded to 5 half-day sessions and includes medical oncology, surgical oncology and gynecologic oncology. Referrals to palliative care have grown consistently covering multiple cancer diagnosis and including the entire oncology staff instead of a few champions. Increase in outpatient utilization has also spurred more early and appropriate inpatient palliative care utilization. Staff have moved from crisis-only use of outpatient palliative care to a co-management model. Conclusions: Outpatient palliative care can be successfully integrated into an NCI academic medical center oncology practice. (Note: More detailed data will be presented at the conference on all of the trends mentioned above.)
Predictors of referral to outpatient specialty palliative care (SPC) in gynecologic cancer (GC) patients.
Authors: Ruskin Rachel , Rowland Michelle Renee , Moore Katherine N , Slaughter Katrina , Walter Adam , Landrum Lisa Michelle , Walker Joan L. , Matzo Marianne
Published: February 2017

159

Background: Prior studies in GC patients have described predictors of inpatient palliative care (PC) consultation, but predictors of outpatient SPC consultation have not been elucidated. We sought to identify factors predictive of referral and associated care outcomes. Methods: We performed a cross-sectional study of GC patients seen in the gynecologic oncology clinic at a comprehensive cancer center over a three month period. As a part of routine care, patients completed a symptom questionnaire. Patients previously seen at the outpatient PC clinic were compared to those who had not with respect to demographics, disease characteristics, symptom scores, and provider factors using univariate statistics. A multivariate model was created to identify independent predictors of referral. Results: 913 patients completed the symptom survey. 76 patients (8%) had been seen in the outpatient PC clinic. Disease factors associated with referral included site (p < 0.01), stage (p < 0.01), evidence of disease (p < 0.01), active treatment (p < 0.01), and time point in the disease trajectory (p < 0.01). Women with moderate to severe pain (p < 0.01), sadness (p = 0.03), distress (p < 0.01), fatigue (p < 0.01), neuropathy (p = 0.03), and sexual dysfunction (p < 0.01) were more likely to have seen PC. Marital status, number of symptoms, and patient provider were also predictive of referral (all p < 0.01). In a multivariate model, site, stage, number of symptoms, moderate to severe sexual dysfunction, and provider were independently associated with referral. Compared to women who had not been referred, patients seen in the PC clinic were more likely to have a health care proxy documented in the electronic medical record (p < 0.01). Among patients with related symptoms, patients referred to PC more often had an opioid prescribed for pain (p < 0.01) and medications prescribed for depression (p < 0.01), anxiety (p = 0.04), insomnia (p < 0.01), and fatigue (p < 0.01). Conclusions: Women with depression, anxiety, insomnia, and fatigue were more likely to receive pharmacologic treatment for these symptoms from a SPC provider. Future research should identify referral triggers for those patients most likely to benefit from outpatient SPC consultation.
Integration of palliative care services into standard oncology practice at diagnosis of metastatic lung cancer at VA New York Harbor Healthcare System.
Authors: Rivera Mercado Felix Manuel , Luhrs Carol , Beal Alice , Langdon Maura , Secrest Joan , Talbot Susan M.
Published: February 2017

165

Background: The 2012 ASCO provisional clinical opinion addressed the integration of palliative care into standard oncology practice at the time a person is diagnosed with metastatic or advanced cancer. The inclusion of Palliative Care among the National Quality Forum (NQF) framework represented a major advance in palliative care. NQF metrics include chemotherapy administered in the last 14 days of life, hospice less than 3 days before death, ICU or hospital admission, more than one Emergency Room visit in the last 30 days, and death in hospital. Although the use of hospice and other palliative care services has increased, many are enrolled in hospice less than 3 weeks before death. By improving quality of life, cost, and survival in patients with metastatic cancer, palliative care has increasing relevance for the care of patients with cancer. Methods: Retrospective chart review study of lung cancer patients diagnosed at VA from 2010-2013. Inclusion criteria: > 18 years of age with new diagnosis of metastatic lung cancer. Exclusion criteria: < 18 years of age, Stage I-III lung cancer. Results: Total of 125 patients were diagnosed with Stage IV lung cancer. The mean time from diagnosis to death was only 185 days (6.1 months). The VA NYHHS patients were more likely to visit the ED, be admitted to the hospital and ICU in the last 30 days of life, and subsequently die in the hospital. Conclusions: Several confounders were identified, including climate related closure of facilities (2012 Sandy storm), lack of social support, low ICU admission criteria, burial benefits for patients dying in a VA, and delay in transition to Hospice. Currently 392 patients with stage IV solid tumors diagnosed 2010-2014 are being studied. [Table: see text]
How to implement Institute of Medicine (IOM) 2013 recommendations on supportive oncology in community setting.
Authors: Weldon Christine B. , Trosman Julia Rachel , Berardi Rosa
Published: February 2017

172

Background: The IOM 2013 report recommends supportive oncology services from diagnosis through survivorship and end of life. We examined what community institutions need in order to implement IOM recommendations. Funded by the Coleman Foundation. Methods: We conducted a survey of 35 institutions in a large urban area (13 cancer centers; 14 stand-alone cancer support centers, and 8 hospices) on institutional needs in implementing IOM recommendations. Results: Survey response rate was 100%. Respondents agreed on 8 of the top 10 priorities across the three organization types (Table). Local inter-institutional collaboration leveraging respective resources and facilitating care consistency across sites was the most frequently noted need. It was followed by the need for stratified care processes based on patient need and improved supportive oncology reimbursement. Priorities differed between Cancer Centers and other institution types on Consolidated screening tools* (p = .05, .09) and Care process for family / caregiver** (p = .006, .04). Conclusions: Supportive oncology care processes and tools are needed to implement IOM recommendations in the community. Our findings inform a roadmap for practical collaborative implementation of the IOM recommendations. Differing priorities across cancer institution types should be further explored and addressed within the roadmap. [Table: see text]
Patterns of storage, use, and disposal of opioids among cancer patients presenting to the emergency center.
Authors: Reddy Akhila Sunkepally , Silvestre Julio , De la Cruz Maxine Grace , Wu Jimin , Liu Diane D , Bruera Eduardo , Todd Knox H.
Published: February 2017

184

Background: Approximately 75% of prescription opioid abusers obtain the drug from an acquaintance. Improper opioid storage, use, and disposal along with lack of patient education may lead to increased availability of the drug for abuse by others. Our aim was to determine the opioid storage, use, and disposal patterns in patients presenting to the emergency center (EC) of a comprehensive cancer center. Methods: We surveyed 113 cancer patients receiving opioids for at least 2 months and collected information regarding opioid use, storage, and disposal. Unsafe storage was defined as storing the opioids in plain sight and sharing or losing their opioids was defined as unsafe use. Results: The median age was 53 years, 55% were female, and 64% were white and 86% had advanced cancer. 19% of the patients had history of illicit drug use and 24% reported that drug abuse is prevalent in their neighborhood. 59% obtained the opioid from their oncologist and 6% believed they were prescribed more medication than required. Of the 113 respondents, 36% stored opioids in plain sight, 53% kept them hidden but unlocked, and only 15% locked their opioids. 73% agreed that they would use a lockbox to store their opioids if given one, 78% were unaware of proper opioid disposal methods, and 67% had unused opioids at home. Only 13% previously received education about safe disposal of opioids. Patients who reported that others have asked them for their pain medications (P = .004) and those who would use a lockbox if given one (P = .019) were more likely to keep them locked. 13 patients (12%) used opioids unsafely by either sharing (5%) or losing (8%) them. Patients who reported to being prescribed more pain pills than required (P = .032), others having asked them for their pain pills (P = .06), being unemployed (P = .07), and those who were unaware of drug take-back programs (P = .06) were more likely to participate in unsafe use. Overall, 77% (87) of the patients reported unsafe storage, unsafe use, or possessed unused opioids at home. Conclusions: A large number of cancer patients improperly and unsafely store, use, or dispose of opioids. More research is needed to determine whether patient education has an effect on minimizing prescription opioid abuse.
Incidence and costs of thromboembolic events in cancer patients: A study on four major cancer localization.
Authors: Borget Isabelle , Vainchtock Alexandre , Martelli Nicolas , Scotte Florian
Published: February 2017

185

Background: Venous thromboembolic event (VTE) is a common complication for cancer patients, leading to hospitalizations that increase the burden of cancer management. Our study aimed to estimate the incidence and costs of hospitalizations for VTE, in French patients with breast cancer (BC), colon cancer (CC), lung cancer (LC) or prostate cancer (PC), four of the most frequent cancers in France. Methods: We used the French national hospital database (PMSI) to select new patients with BC, CC, LC or PC in 2010, who had at least one VTE-related hospitalization during the following two years. VTE-related stays and patients were identified using the disease-specific ICD-10 codes. Hospital costs were calculated over stays for which VTE was considered as primary/related diagnosis. Costs were estimated from the healthcare system perspective, using the French official tariffs. Results: Among 194,964 patients newly diagnosed in 2010 with BC, CC, LC or PC in 2010, 8,909 (4.6%) were hospitalized for a VTE or experienced VTE at hospital, representing, 12,880 hospital stays. During the two-year follow-up, 2,053 (23.0%) patients were re-hospitalized for a VTE recurrence, representing 3,969 stays (30.8% of admissions for VTE). For one patient with VTE who did not experience recurrence, the mean hospital cost over two years ranged from €3,302 to €3,674. This amount was dramatically increased for patients with recurrent VTE, as it ranged from €5,441 to €5,692 per patient. Hospitalizations for VTE associated with those 4 types of cancer only were responsible for an overall expenditure reaching €13.30 million over two years, including €1.82 million due to recurrent events. Conclusions: VTE-related cancer hospitalizations remain frequent and induce a notable cost. Prevention and management in respect to guidelines would be an efficient way to reduce the incidence of this complication and moderate its economic cost. [Table: see text]
Development of a mobile application (app) for improving symptoms and adherence to oral chemotherapy in patients with cancer.
Authors: Nisotel Lauren , Amoyal Nicole , Fishbein Joel , MacDonald James , Pirl William F. , Temel Jennifer S. , Lennes Inga Tolin , Safren Steven A. , Buzaglo Joanne S. , Jethwani Kamal , Greer Joseph A.
Published: February 2017

189

Background: An advantage of oral chemotherapy is ease of administration, yet patients and family caregivers receive less support for adherence and monitoring of side effects. Effective interventions should support adherence to oral chemotherapy. We conducted qualitative interviews with patients, clinicians, and relevant stakeholders to inform the development of a proposed mobile app intervention to improve adherence and symptoms to oral chemotherapy. Methods: We conducted qualitative interviews and focus groups with multiple stakeholder groups (18 oncology physicians, 8 healthcare representatives, 8 cancer practice administrators, 18 patients and family members). Eligible patients had a diagnosis of cancer, a prescription for oral chemotherapy, cancer care at the MGH Cancer Center, and access to a smart phone. Stakeholders and clinicians evaluated the study approach, patient engagement, and intervention implementation. Patients reviewed wireframes of the mobile app to evaluate the components, usability, feasibility, and acceptability. Results: The app features include a treatment plan, medication reminders, symptom reporting, and cancer-specific resources. The themes from the qualitative interviews suggest that this mobile app would be helpful in improving adherence to oral chemotherapy and symptom management. Patients reported the wireframes to be acceptable and potentially user-friendly. Clinicians found that ongoing symptom reports would be helpful for proactively managing patients’ symptoms. Stakeholders recognized the importance of an app with functional tools to aid adherence and symptom management. All parties agreed that app features should remain simple, avoid undue burden, and thus enhance usability. Conclusions: Our findings suggest that a mobile app could be helpful for adherence and improving symptoms to oral chemotherapy in patients with cancer. Patients and clinicians rated the wireframe content favorably and commended the different features. We refined and finalized the mobile app based on feedback from the qualitative interviews. These findings support our plan to test the efficacy of this intervention in a randomized controlled trial. Clinical trial information: NCT02157519.
Personalized symptom goals in symptom assessment: A prospective multicenter study.
Authors: Hui David , Shamieh Omar M. , Paiva Carlos Eduardo , Perez-Cruz Pedro Emilio , Muckaden Mary Ann , Park Minjeong , Bruera Eduardo
Published: February 2017

190

Background: PSG is a novel measure to assess treatment response in symptom management. In this multicenter prospective longitudinal observational study, we examined the PSG for 10 common symptoms in patients with advanced cancer, and identified the factors associated with PSG intensity and PSG response. Methods: We enrolled patients with advanced cancer seen at 5 outpatient palliative care clinics (USA, Jordan, Brazil, Chile and India). We assessed the intensity of 10 symptoms using the Edmonton Symptom Assessment Scale at first consultation visit and then a second visit 14-34 days later. We also assessed the PSG by asking patients “At what level would you feel comfortable with this symptom?” using the same 0-10 numeric rating scale for each symptom. Response was defined as symptom intensity ≤ PSG. We used multivariate logistic regression to determine factors associated with PSG intensity and PSG response. Results: 728 patients were enrolled from 5 palliative care clinics. The average age was 57 (range 19-85), 361 (50%) were female, and 29 (31%) were White. The medianPSG was 1/10 for nausea, 2/10 for depression, anxiety, drowsiness, well-being, dyspnea and sleep, and 3/10 for pain, fatigue, and appetite. In multivariate logistic regression, Asian ethnicity (odds ratio [OR] 2.4-8.2, P < 0.001), CAGE positivity (OR 1.7-2.3, P < 0.05) and higher baseline symptom intensity (ORs 1.08-1.15 per point, P < 0.03) were associated with PSG ≥ 2 for essentially all symptoms. At visit 2, 34%-73% of patients had a PSG response, which represents a significant improvement compared to the first visit (P < 0.05 except for depression, drowsiness and well-being). PSG response was associated with baseline PSG intensity (ORs 1.3-1.5 per point, P < 0.001) and ethnicity (P < 0.02) for physical symptoms, and male sex (ORs 1.45-1.65, P < 0.02) for psychological symptoms. Conclusions: PSG was 3 or lower for a majority of patients, and varied according to ethnicity, alcoholism and symptom intensity. PSG response allows clinicians and researchers to tailor treatment goals, while adjusting for individual differences in scale interpretation and factors associated with symptom response.
Effects of methylphenidate (MP) on symptom couplets associated with cancer-related fatigue (CRF) in patients with advanced cancer.
Authors: Yennu Sriram , Williams Janet L. , Park Minjeong , Liu Diane D , Bruera Eduardo
Published: February 2017

191

Background: Psychostimulant clinical trials on CRF in pts with advanced cancer suggest mixed effects on CRF. The aim of this study was to determine the effects of MP and placebo (PL) on the pts with clinically significant CRF and associated symptoms such as depression, sedation, or depression and sedation (couplets). Methods: Secondary analysis of pts who received MP as a part of 3 prospective controlled clinical trials on MP for CRF. Pts were categorized one of 4 groups, fatigue+depression (FD), fatigue+ drowsiness (FDR), fatigue+drowsiness+depression (FDDR) or fatigue only (F), and outcomes were change in FACIT-F subscale and ESAS -fatigue scores at Day 8 of treatment with MP and PL. Repeated measures analysis was applied to assess the effects of treatment over time (Day8 – Day0) among the 4 groups on FACIT-F subscale and ESAS fatigue. Results: Of the 322 evaluable pts (34 FD, 100 FDR, 78 FDDR, 107F), at Day 8 there was a significant improvement in the ESAS fatigue in MP compared to PL groups [median (IQR)-2 (-4, -1) vs 2 (-3.5,0),p = 0.03, but the difference in the change of FACIT-F between the groups was not significant [median(IQR) 8(2,17) VS7(0,12), p = 0.09). Repeated measures analysis on FACIT-F with pairwise interactions(Time X Baseline Group, Time X Treatment) shows that regardless of treatment, the increase of FACIT-F from Day0 to Day8 was significantly different between FD and F (p = 0.001) and between FDDR and F (p = 0.03).However the change over time was not significantly different between two treatment groups (p = 0.23). Furthermore, the repeated measure analysis including three term interactions(Time X Treatment X Baseline Group) indicates no significant the treatment effect on FACIT-F over time is not significantly different among the four groups (p = 0.89). Similarly, there is no significant treatment effect in ESAS fatigue score over time among the four groups. Conclusions: Although there was a general improvement in CRF (FACIT-F) scores over time, there was no significant treatment effect on this improvement over time among F or FD, or FDR, or FDDR groups defined by fatigue/depression/sedation in the whole study population. Further studies are needed.
Wearable sensor-based balance training in older adult cancer patients with chemotherapy-induced neuropathy: A randomized controlled trial.
Authors: Schwenk Michael , Garland Linda L. , Grewal Gurtej Singh , Holloway Dustin , Muchna Amy , Mohler Jane , Najafi Bijan
Published: February 2017

195

Background: Chemotherapy-induced peripheral neuropathy (CIPN) can affect lower extremity joint proprioception leading to balance deficits and increased fall risk. This study evaluated the effect of a sensor-based exercise program on improving postural control in cancer patients with CIPN. Methods: Twenty two cancer patients (Age 70.3±8.7 years) with objectively confirmed CIPN (vibration perception threshold test, VPT > 25 Volt) were randomized to twice weekly x 4 weeks sensor-based training including weight shifting and virtual obstacle crossing with real-time visual feedback of lower-extremities through wearable wireless sensors (intervention group, IG, n = 11) or no intervention (control group, CG, n = 11). Outcome measures included changes in sway of ankle, hip, and center of mass (CoM) in both medio-lateral (ML) and anterior-posterior (AP) directions during 30 second standing in feet closed position (both feet next to each other) with eyes open (EO) and eyes closed (EC), and semi-tandem position (big toe by arch of other foot) with EO, at baseline and post-intervention. All assessments were made using validated wearable sensors. Results: VPT score averaged 49.6 ± 26.7 Post intervention, sway of hip, ankle and CoM (ML) were significantly reduced in the IG compared to the CG during FC position (p = .010-.022). During the more challenging position of semi-tandem, all sway parameters except ankle were significantly reduced (p = .008-.039). Effect sizes were moderate-large (eta squared = .255-.388). Conclusions: This randomized controlled study using a novel wireless sensor-based training demonstrated improvements in balance in CIPN patients by measures of balance that have been related to fall risk. We speculate that the sensor-based training with real-time visual joint position feedback provided participants with enhanced information about joint movements and motor error in order to compensate for deteriorated/lost lower extremity joint proprioception from CIPN. This balance training system can be easily translated to an in-home setting and may decrease fall risk and thus improve cancer patients’ quality of life. Clinical trial information: NCT02043834.
Evaluation of hyponatraemia in lung cancer patients: A U.K. teaching hospital experience.
Authors: Jain Ankit , Jafri Mariam , Mascall Sophie , Alam Salma Moona , Thomas Rhian , Kendrick James , Thompson Joyce
Published: February 2017

197

Background: Hyponatraemia, defined as a serum Na < 135mEq/L, is the commonest electrolyte abnormality in oncology practice. We describe the demographics, oncological management and response of hyponatraemia to oncological treatment modalities in our patient group. Methods: We retrospectively analysed serum sodium levels in lung cancer patients admitted to a teaching hospital in the UK between 2007 and 2013. Data was collected on baseline demographics, histology, tumour stage and grade of hyponatraemia. Mild hyponatraemia was defined as a serum sodium between 130-135mEq/L, moderate 125-129mEq/L and severe as < 124mEq/L. Results: 182 (108 male; 74 female) patients with lung cancer and documented hyponatraemia were hospitalised between 2007 and 2013. The median age of patients on admission was 69.2 years (range 33-92 years). 119(65%) had mild, 58(32%) moderate and 5(3%) severe hyponatraemia. 74(40%) were adenocarcinomas, 58(32%) squamous carcinomas, 43(24%)SCLC and 7(4%) had unspecified NSCLC. 89(49%) had metastatic disease on diagnosis. 18/43(42%)small-cell, 14/58(33%) squamous, 23/74 (31%)adenocarcinoma patients had moderate to severe hyponatraemia. 132(74%) of this cohort had active oncological treatment: 93(51%) chemotherapy, 25(14%) radiotherapy, 17(9%) surgery whilst 47(26%) had best supportive care. 28(15%) had a biochemical response to their treatment, 11(39%) of these patients were adenocarcinomas, 10(36%) squamous carcinomas and 7(25%) SCLC. Conclusions: Hyponatraemia in lung cancer patients is widely distributed in various age groups and histological subtypes. Among those admitted with hyponatraemia, severe cases were rare. Higher rates of SIADH are seen in SCLC than in any other malignancy and proportionately more SCLC patients had moderate - severe hyponatremia than NSCLC. Hyponatraemia responds to active oncological treatment including chemotherapy, radiotherapy and surgery. Although historically, hyponatraemia is considered a poor prognostic marker and has been associated with shorter survival duration, this should not preclude active oncological management. Further studies are needed to evaluate the prognostic value of hyponatraemia and its treatment in cancer patients.
Palliation of ulcerative breast lesions with radiation.
Authors: Vempati Prashant , Knoll Miriam , Dharmarajan Kavita Vyas , Green Sheryl , Tiersten Amy , Bakst Richard Lorne
Published: February 2017

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Background: Patients with advanced breast cancer may experience ulcerative breast lesions. Breast cancer with ulcerative lesions has been shown to severely affect a patient’s quality of life (QoL). The role of palliative radiation therapy (RT) in the management of ulcerative breast lesions needs to be further explored. Methods: IRB-approval was obtained to retrospectively review the radiation treatment records for all patients who underwent palliative RT for breast cancer at our urban academic medical center. A total of 13 patients were identified, and we herein report their demographics, treatment characteristics, and clinical outcomes. Results: The mean age of the patients receiving palliative RT for ulcerative breast cancer was 64 years. All patients had stage IV disease when they were evaluated for RT. All patients received prior systemic chemotherapy with a mean of four chemotherapeutic agents, the most common of which was Capecitabine. The mean radiation dose received for palliative RT was 27.54 Gy in 11 fractions with a median dose of 30 Gy in 15 fractions. Six (46%) of the patients received prior RT to the same breast, with a median dose of 59.5 Gy in 31 fractions. Among these six patients, the average interval between initial RT and ulcerative breast lesion was 69.5 months. The median overall survival in all patients since ulcerative breast lesion was 5 months and the mean survival did not differ between patients with previous history of RT and RT-naïve patients (4.50 vs. 4.57; p = 0.95). Six out of the 9 (69%) patients who received ≥ 30 Gy reported clinical improvement, whereas none of the 4 patients who received < 30 Gy reported any benefit. There were no radiation-associated toxicities reported by patients. Conclusions: These data suggest that palliative RT ( ≥ 30 Gy) is an efficacious treatment for ulcerative breast cancer with minimal toxicity. Prior RT should not be a contraindication as patients with previous history of RT have similar outcomes compared to RT-naïve patients.
Association between oncologists’ dispositional affect and depressive symptoms in their patients with metastatic cancer.
Authors: Pirl William F. , Lerner Jennifer , Eusebio Justin , Traeger Lara , Fields Lauren , El-Jawahri Areej , Greer Joseph A. , Temel Jennifer S.
Published: February 2017

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Background: While caring for patients with metastatic cancer can be emotional, relationships between the emotions of oncologists and their patients have not been examined. As patients and oncologists read emotional cues in encounters, emotions of one or both may impact the other. We explored associations between dispositional affect, tendencies to emotionally respond to situations in certain ways, in oncologists and depressive symptoms in their patients with newly diagnosed metastatic lung and gastrointestinal (GI) cancers. Methods: As part of an ongoing trial of early palliative care, participants were assessed at baseline for depressive symptoms (Patient Health Questionnaire-9, PHQ9) within 8 weeks of diagnosis with metastatic lung and GI cancers. Oncologists providing care for these patients completed the Positive and Negative Affect Scale (PANAS), a validated measure of dispositional affect with positive and negative dimensions. Associations between patient depressive symptoms and oncologists' positive and negative dispositional affect were tested with linear regression models. Results: Sixteen of the 18 oncologists with patients in the trial completed the PANAS. Among 323 participants with baseline assessments, 277 (86%) had oncologists who completed the PANAS. Mean age=64.6, 129 (46%) were female, 159 (57%) had GI and 118 (43%) lung cancer, and mean PHQ9 score=6.5. Positive and negative dispositional affect were not associated with oncologists’ sex, years from training, hours in clinic, and cancer specialization. Patient depressive symptoms were significantly higher if their oncologists reported greater negative dispositional affect (p=.04). The relationship remained significant adjusting for patient age, sex, cancer type, ECOG PS, smoking, and number of oncology visits (β=.13, t=2.1, p=.04). PHQ9 scores were not associated with oncologists’ positive dispositional affect. Conclusions: Depressive symptoms in patients with metastatic lung and GI cancers appear to be associated with their oncologists’ negative dispositional affect. Determining the direction of the association may lead to new ways of improving patients and/or oncologists moods.
Mobile application of cognitive behavioral therapy for anxiety and advanced cancer.
Authors: MacDonald James , Amoyal Nicole , Nisotel Lauren , Perez Giselle Katiria , Traeger Lara , Temel Jennifer S. , Pirl William F. , Safren Steven A. , Greer Joseph A.
Published: February 2017

220

Background: We previously demonstrated the efficacy of a brief, in-person cognitive behavioral therapy (CBT) program for alleviating anxiety in patients with advanced cancer. The aim of the current study was to adapt this program to an interactive, patient-centered mobile tablet application (CBT app) for self-delivery, ideally to enhance dissemination and patient access to the CBT intervention. Methods: Development of the CBT app proceeded in two phases. First, we enrolled five patients with advanced cancer and anxiety (HADS-Anxiety subscale score ≥ 8) to review a preliminary CBT app prototype and to provide qualitative feedback regarding intervention acceptability and utility. Using content analysis of the recorded data, we identified key themes in patient feedback and refined the CBT app content and design accordingly. Finally, a multidisciplinary team of clinical researchers (n=7) specializing in healthcare technology, psychiatry, and psychology conducted an extensive iterative review process to vet and finalize the CBT app intervention. Results: Patients reported that the CBT app content was comprehensible, easily navigated, and helpful in addressing a breadth of concerns relevant to patients with anxiety and advanced cancer. Specifically, patients reported that case examples, tailored feedback, accessible interactive features, and content summaries were important for engagement with the program. The multidisciplinary study team used patient feedback to adapt the CBT app prototype to a tablet design consisting of six modules that teach skills for practicing relaxation, staying present-focused, coping with fears related to cancer, and pacing activities. To enhance patient engagement, features also included homework assignments, symptom distress tracking, and tailored algorithms and branching logic based on patient responses. Conclusions: Patient interviews confirmed acceptability of the CBT app content. Expert clinician feedback also supported the tablet design for self-administration of the intervention to reduce patient burden. We are currently conducting a randomized controlled trial to assess the efficacy of the CBT app for improving anxiety symptoms in patients with advanced cancer. Clinical trial information: NCT02286466.