bluuebunny/crossref_metadata_2025 huggingface dataset:
Enhancing palliative care patient access to outpatient and outreach counseling services.
Authors: Guzman Diana , Bruera Eduardo , Williams Janet L. , Najera John M , Raznahan Monica , Ann-Yi Sujin , Carmack Cindy L.
Published: November 2017

184

Background: MD Anderson’s interdisciplinary out-patient clinic, palliative care team includes mental health professionals who provide psychological care, including 3 full time Master’s level counselors. Counseling sessions are offered during the patient’s clinic appointments. To increase opportunity and access for additional counseling, patients are offered follow-up counseling through an outreach program which includes videoconferencing or telephone sessions. The data presented represents almost 2 years of our Master’s level clinicians’ practices. Methods: Retrospective chart review of 2041 consecutive patients (3606 total contacts) seen for psychology counseling services in the Supportive Care Center between 6/2015 and 3/2017. Results: Counselors saw 2041 consecutive patients (52% of the patients seen at the out-patient Supportive Care Center). Most patients only had 1 session in clinic (63%); almost 1/3 received 2-5 sessions (33.9%). Median time for the follow-up visit was 30.5 days. Approximately 25% (N = 511) were offered outreach services; 79% (N = 405) of those offered received these services. Median number of outreach sessions received was 1 (57%); 2-5 (38%); 6-9 (4%) and 10+ (1%). Sessions lasted 10-15 minutes (58%); 20-35 minutes (31%); and 40+ minutes (11%). Patient preferred mode of outreach included telephone (93%), Facetime (5.0%), and videoconferencing (2%). In total, 798 outreach sessions were provided representing 18% of total counseling sessions offered. Conclusions: The out-patient palliative care service is able to offer psychological assessment and counseling to more than half of the patients they serviced due to the addition of 3 Master’s level counselors embedded in the clinic. Follow-up counseling for these patients can be challenged for those residing in rural areas, with limited resources and/or transportation problems, and with physical limitations that make travel difficult. Our outreach program has successfully enhanced access to services to patients who otherwise may have had limited to no follow-up psychosocial care.
Illicit substance use and opioid misuse in adolescent and young adult (AYA) patients with cancer.
Authors: Oberoi-Jassal Ritika , Chang Young Doo , Smith Joshua , Rajasekhara Sahana , Desai Vijay , Fenech Alyssa L , Reed Damon R. , Portman Diane , Donovan Kristine A.
Published: November 2017

205

Background: Rates of illicit substance use and misuse of opioid medications are high in the adolescent and young adult (AYA) general population. Despite this, screening for substance use and opioid misuse is not standard in the care of AYA oncology supportive/palliative care. To inform our clinical practice, we sought to determine the prevalence of illicit substance use and potential opioid misuse in AYA cancer patients relative to adult patients and to examine correlates of use and misuse. Methods: We conducted retrospective chart review of patients newly referred to an outpatient palliative care clinic between 2014 and 2016. Results: Consecutive patients (N = 963) underwent urine drug testing as part of their initial visit; 16% of patients were between 18 and 39 years of age. Rate of illicit drug use was 31% for AYAs and 19% for adults. AYAs were nearly 2 times more likely to have positive results for marijuana (OR = 1.79; 95% CI = 1.19 – 2.69) and nearly 3 times more likely to test positive for amphetamines (OR = 2.94; 95% CI = 1.15 – 7.49). AYAs were no more likely than adults to test positive for cocaine, barbiturates or heroin. In univariate analyses, only male sex and being single, and no clinical characteristics or symptom scores, were significantly associated with illicit substance use (ps < .05). AYAs were no more likely than adults to test positive for the presence of opioids, not currently prescribed (OR = 1.07; 95% CI = 0.70 – 1.65). No symptoms scores or demographic and clinical characteristics were significantly associated with misuse. Conclusions: AYA patients demonstrated a high rate of illicit substance use and similar rate of potential opioid misuse relative to adult patients. Findings suggest AYAs may benefit from consistent screening, support and treatment for substance use and potential opioid misuse during anticancer and cancer-related therapies.
Factors associated with participating in formal support services among family caregivers of older adults with poor-prognosis cancers.
Authors: Dionne-Odom J Nicholas , Applebaum Allison , Ornstein Katherine , Azuero Andres , Warren Paula , Taylor Richard A. , Rocque Gabrielle Betty , Kvale Elizabeth Ann , Demark-Wahnefried Wendy , Pisu Maria , Partridge Edward E. , Martin Michelle Y , Bakitas Marie
Published: November 2017

21

Background: Family caregivers of persons with cancer are at high risk for distress and may benefit from formal support services. The purpose of this study was to describe cancer family caregiver’s use of and desire for formal support services. Methods: Cross-sectional mail survey conducted in communities of eight cancer centers in Tennessee, Alabama, and Florida. Family caregivers of Medicare beneficiaries with pancreatic, lung, brain, ovarian, head and neck, hematologic, and stage IV cancers reported support service use and completed validated measures of depression, anxiety, burden, preparedness, and health. Results: Caregivers(n = 294) were on average age 65.5 years and mostly female (72.8%), white (91.2%), and care recipients’ spouse/partner (60.2%). Patients averaged 75.3 years and were mostly male (54.4%). Formal support services were used by 32.0% (n = 94) of all caregivers; 4.4% used therapy or counseling, 19.7% received education and training; and 11.2% received assistance from local, state, or national organizations. Twenty-eight percent of all caregivers were “mostly or “extremely” interested in receiving support services; of those, 44% had high depressive symptoms, 52.3% had high anxiety symptoms, and 36.4% in the lowest quartile of preparedness. In multivariate analyses, participation in services was significantly associated with lower objective burden, higher preparedness, not working, and not being the patient’s spouse. Being “mostly” or “extremely” interested in support services was significantly associated with being a minority, shorter durations of caregiving, and with higher stress burden. Conclusions: While distressed and underprepared family caregivers reported strong interest in formal support services, only a small proportion accessed these services. Strategies to increase service use may include targeting those caregivers who are still early in their caregiving experience and who report high stress burden.
A systematic review and meta-analysis of randomized controlled trials to evaluate the risk of fatigue and pain among patients with metastatic solid tumors treated with cabozantinib.
Authors: Han Myat M. , Thein Kyaw Zin , Zaw Myo , D'Cunha Luke , Perisetti Abhilash , Hardwicke Fred L. , Tijani Lukman
Published: November 2017

214

Background: Fatigue and pain notably contributed to the quality of life of cancer patients undergoing chemotherapy. Cabozantinib inhibits the activity of VEGFR, AXL, MET and other receptor tyrosine kinases which are essential in tumor development and progression. Yet the impact of this agent on fatigue and pain is a considerable safety concern. We undertook a systematic review and meta-analysis of randomized controlled trials (RCT) to determine these risks. Methods: MEDLINE, EMBASE databases and meeting abstracts from inception to March 2017 were queried. Phase 3 RCTs that mention fatigue, asthenia, back pain, pain in arms and legs, arthralgia, muscle spasm and bone and musculoskeletal pain as adverse effects were incorporated in the analysis. Mantel-Haenszel method was used to calculate the estimated pooled risk ratio with 95% confidence interval (CI). Results: Three phase 3 RCTs with a total of 1999 patients were eligible for analysis. Studies compared cabozantinib (C) vs everolimus, C vs placebo, C vs prednisone, were included in the analysis. The relative risks (RR) of all-grade adverse effects were as follows: fatigue, 1.34 (95% CI: 1.19- 1.50, p < 0.0001); asthenia, 1.48 (95% CI: 1.06- 2.06, p = 0.02); back pain, 1.08 (95% CI: 0.84- 1.38, p = 0.52); pain in arms and legs, 1.44 (95% CI: 1.12- 1.84, p = 0.004); arthralgia, 0.98 (95% CI: 0.70- 1.36, p = 0.91); muscle spasm, 2.59 (95% CI: 1.63- 4.12, p < 0.0001); bone pain, 1.22 (95% CI: 0.35- 4.21, p = 0.74); and musculoskeletal pain, 0.64 (95% CI: 0.42- 0.96, p = 0.03). The RR of high-grade adverse effects were as follows: fatigue, 1.84 (95% CI: 1.36- 2.48, p < 0.0001); asthenia, 2.02 (95% CI: 1.37- 2.99, p < 0.0001); back pain, 1.17 (95% CI: 0.69- 1.98, p = 0.54); pain in arms and legs, 2.93 (95% CI: 1.12- 7.63, p = 0.02); arthralgia, 0.82 (95% CI: 0.39- 1.70, p = 0.59); bone pain, 1.20 (95% CI: 0.28- 5.10, p = 0.79); and musculoskeletal pain, 1.34 (95% CI: 0.38- 4.64, p = 0.64). Conclusions: Cabozantinib increased the risk of all-grade and high-grade fatigue, asthenia and pain in arms and legs as well as all-grade muscle spasm whereas the risk of musculoskeletal pain was lower in the study arm, favoring cabozantinib.
Risk factors and prophylaxis of irinotecan induced cholinergic syndrome in sight of supportive care.
Authors: Fujii Hiroyuki , Hirata Taizo , Mura Takuya , Okada Yuko , Ito Takuo , Ozaki Shinji , Tashiro Hirotaka , Mizunoe Tomoya , Kohno Hiroshi , Nakano Kikuo
Published: November 2017

216

Background: Irinotecan Induced Cholinergic Syndrome (IICS), manifesting in such events as early diarrhea and diaphoresis, is well-known adverse effect of irinotecan. These symptoms occur within the first 24 hours of irinotecan administration and can be ameliorated with anticholinergic agents. Although IICS is transient and tends to be underestimated, diarrhea and abdominal pain during drug infusion are inflictive and make patients reluctant to undergo anticancer therapy. Methods: First, to identify the risk factors that are associated with IICS, 132 consecutive patients who were treated with a chemotherapeutic regimen that included irinotecan at Kure Medical Center between 2012 and 2017 were retrospectively analyzed from the aspect of sex, age, dose, cancer type, regimen, kidney function, and renal function. Secondly, to determine the response rate of butylscopolamine bromide for IICS, we injected butylscopolamine bromide 20mg into the irinotecan infusion bag and administered both agents through the intravenous line together to patients who experienced IICS. Results: IICS occurred 14 of 132 patients (10.6%); these 14 patients were given butylscopolamine bromide by coinjection for total 119 cycles. Univariate analysis indicated that dose (p = 0.0029), cancer type (p = 0.0023) and regimen (p = 0.0005) was associated with IICS. Patients with symptoms tended to be administered a higher irinotecan dose than those without symptoms (127.9±20.4mg/m2 and 99.6±34.1mg/m2). By logistic regression analysis, a higher dose (dose > 105mg/m2) was identified a significant risk factor for IICS (Odds Ratio = 10.9; 95% Confidence Interval: 2.0 to 96.7; p = 0.0121). 13 patients (105 cycles) of 14 patients (119 cycles) who were administered butylscopolamine bromide, experienced complete or partial improvement of IICS. The response rate was nearly 90%. Conclusions: A higher dose of irinotecan is a significant risk factor for IICS. To avoid creating a disincentive for patients to undergo anticancer therapy, the prevention of IICS is paramount. As prophylaxis of IICS, mixing butylscopolamine bromide into the irinotecan infusion bag was remarkably effective.
Novel approach for cancer-related fatigue: A double-blind randomized clinical trial.
Authors: Sette Claudia Vaz De Melo , de Alcântara Barbara Bonaparte Ribas , Cruz Felipe Melo , Schoueri Jean Henri Maselli , Cubero Daniel de Iracema Gomes , Del Giglio Auro
Published: November 2017

234

Background: Fatigue is one side effect of cancer and its treatment, and remains as the most prevalent symptom for those who survived. To date, the search for novel approaches regarding Cancer-Related Fatigue persists. As such, Paullinia cupana – a medicinal plant – has shown promising results for the treatment of chemotherapy-induced fatigue. Methods: We conducted a phase II randomized double-blind clinical trial, in which we compared a standardized dry purified Paullinia cupana extract (PC-18) - in doses of 7.5 mg and 12.5 mg given orally twice a day - to placebo for the treatment of fatigue in women with early breast cancer scheduled to receive their first cycle of adjuvant systemic chemotherapy. Only patients that experienced increase in the score of either BFI, HAD or Chalder fatigue scales following the first cycle of chemotherapy were included. For possible associations between qualitative variables, Chi-square test was used. Poisson regression was used to test for the relationship between the drug used and the outcome regarding the difference assessed in scores aforementioned. The significance level was 5%. The program used was Stata 12.0. This study has been approved by our Institutional Review Board (number: 34327214.1.1001.0082) and participants have all signed informed consent forms. Results: PC-18 on 7.5 mg has not been statistically significant with any improvements on assessed scores when compared to placebo (IRR 0.99 [CI] 0.81 – 1.23, p = 0.958 for BFI; IRR 1.04 [CI] 0.56 – 1.95, p = 0,898 for HAD; IRR 0.95 [CI] 0.75 – 1.19, p = 0.645 for Chalder), while greater dosage (12.5mg) has shown the following outcomes regarding the scores (IRR 0.49 [CI] 0.30 – 0.81, p = 0.005 for BFI; IRR 0.89 [CI] 0.45 – 1.76, p = 0,735 for HAD; IRR 0.99 [CI] 0.80 – 1.23, p = 0.914 for Chalder) in the same comparison. Conclusions: Disregarding preliminary data on previous studies, PC-18 has not shown to be better than placebo. Clinical trial information: 34327214.1.1001.0082.
BMI and health-related quality of life (HR-QoL) in patients with metastatic colorectal cancer (mCRC).
Authors: Formica Vincenzo , Nardecchia Antonella , Pellegrino Rachela , Massimiliani Valentina , Donnarumma Luisa , Giuliano Greta , Renzi Nicola , Mariotti Sabrina , Portarena Ilaria , Laudisi Anastasia , Morelli Cristina , Lucchetti Jessica , Perrone Lorena , Riondino Silvia , Roselli Mario
Published: November 2017

249

Background: Relationship between BMI and HR-QoL has been extensively studied in CRC survivors. Increasing BMI has been recently associated with improved survival in mCRC pts, however data on the relationship between BMI and common HR-QoL measures in mCRC are scarce Methods: The EORTC QLC C30 and the NCCN distress thermometer (DT) and problem list (PL) questionnaires were administered to consecutive mCRC pts candidate for firstline chemotherapy. The effect of BMI on HR-QoL were analyzed using the Kruskal-Wallis and Mann-Whitney tests. The interaction between BMI and other variables of interest (such as inflammatory indexes) for the effect on HR-QoL was also analysed using a logistic regression analysis Results: Of 135 screened pts, 119 completed the questionnaires. A direct association was observed between BMI and GH score, with the score gradually improving from BMI 14 to 21, then plateauing between 21 and 41. A significantly lower GH was observed for BMI < 21 vs > 21 (GH 50 vs 67, p 0.014). DT and BMI were not correlated. BMI was inversely associated with practical problems (mean number of reported problems 0.7 vs 0.4 for BMI < 24 vs > 24, p0.012). The other components inversely associated with BMI were appetite loss, pain and fatigue (which were higher for BMI < 21 , p values 0.033, 0.015 and 0.007, respectively). A direct association with BMI was also observed for social and physical functioning (p values 0.002 and 0.05, respectively). Median BMI in pts with GH score < 25 vs > 25 was 19 vs 25, p 0.05. Percentage of pts with very low BMI (BMI < 21) was 38% vs 2% for pts with GH < 25 vs > 25, respectively, Odds Ratio 32.4, p 0.0007. Among 15 common clinical and biochemical analysed variables, the inflammatory index neutrophil/lymphocyte ratio (NLR) demonstrated a significant interaction with BMI for the effect on GH, with the direct association between BMI and GH only retained in pts with low NLR and a deteriorated GH in pts with high NLR regardless of BMI, test for interaction p 0.013 Conclusions: Low BMI is associated with deteriorated HR-QoL in mCRC pts with low NLR approaching a first-line treatment. Adequate nutritional support and anti-inflammatory approaches would improve HR-QoL in these pts.
Assessment of the impact of the Hospital Anxiety and Depression Scale on the initiation of treatment in newly diagnosed cancer patients in a safety-net hospital.
Authors: Singh Daulath , Singh Annapoorna , Grover Punita , Indaram Mahathi , Malomo Nikki , Cheng An-Lin , Johnson Richard Arden , Madhusudhana Sheshadri
Published: November 2017

250

Background: Distress is a universal symptom in oncologic patients which negatively impact the quality of life and survival. It interferes with the ability to cope with the diagnosis and is a risk factor for non-adherence with treatment. The Hospital Anxiety and Depression Scale (HADS), is used at our institution for distress screening. The aim of our study is to assess the impact of distress, measured by the HADS score, on initiation of treatment in newly diagnosed cancer patients. Methods: We conducted a retrospective chart review of patients with a new diagnosis of cancer, between March 1st, 2014 and December 31st, 2015; who had been evaluated for distress at their first oncology clinic visit. We included only patients who were treated with chemotherapy or chemoradiation, with curative intent. Poisson regression analysis was conducted to investigate the relationship between HADS to treatment initiation while including age, sex, race, insurance status, cancer type, and stage as covariates in the model. Results: A total of 101 patients met the inclusion criteria. The mean age was 54 years, 63% were female and 37% were male. The majority were Caucasians (53%), followed by African-Americans (36%). 56% of the population had Medicaid, and 26% had Medicare and private insurance. The most common cancers were – breast (30%), gastrointestinal (20%), gynecologic (15%) and lung (11%). 64% received chemotherapy and 36% were treated with chemoradiation. We grouped patients into 3 categories based on the HADS score – category 1 with score ≤7 (28%), category 2 with score 8-10 (17%) and category 3 with score ≥11 (55%). The median time to treatment initiation was 28 days. Multivariate Poisson regression analysis did not show any correlation between the HADS score and treatment initiation. Subscales analyses showed that higher depression scores correlate with a delay in treatment initiation (p-value 0.01), while the anxiety scores had no influence (p-value 0.57). Conclusions: In our study, the initial total HADS score did not affect the treatment initiation. Interestingly, depression had an influence on the initiation of treatment in newly diagnosed cancer patients.
The effect of message content and clinical outcome on patients' perceptions of physician compassion: A randomized controlled trial.
Authors: Tanco Kimberson Cochien , Azhar Ahsan , Rhondali Wadih , Rodriguez-Nunez Alfredo , Liu Diane D , Wu Jimin , Baile Walter F. , Bruera Eduardo
Published: November 2017

27

Background: In a previous randomized cross-over study, patients perceived a physician delivering a more optimistic message as more compassionate and professional. However, the impact of the clinical outcome of patient on patients’ perception of physician’s level of compassion and professionalism has not been previously studied. Our aim was to determine if the reported clinical outcome modified the patient’s perception of physician compassion, professionalism, impression, and preference for physician. Methods: 128 advanced cancer patients in an outpatient Supportive Care Center were randomized to complete validated questionnaires about patients’ perception of physician’s level of compassion, professionalism, impression and preference of physician for themselves and their family after watching scripted videos depicting a physician delivering a more optimistic (MO) vs. a less optimistic (LO) message followed by a clinical vignette depicting a worse outcome. Results: Median age was 61 years and 55% were female. There was no difference in compassion score after the vignette for both the MO and LO groups respectively [mean difference (SD): 1.7(8.74) p = 0.4684 vs. 0.89(10.24) p = 0.1225] but there were worse overall impression [mean difference (SD): MO -0.79(1.62) p < 0.0001 vs. LO -1.17(1.91) p < 0.0001] and professionalism scores [MO -0.88(2.25) p = 0.0022 vs. LO -0.76(2.22) p = 0.0094]. In the MO group, preference for the physician for themselves [mean difference (SD) -0.29(0.77) p = 0.0049] and their family [mean difference (SD) -0.29(0.71) p = 0.0009] decreased after the vignette. Conclusions: Seeing a worse clinical outcome did not change the patients’ appraisal of an inappropriately optimistic physician. However, it reduced the overall impression of both physicians that conveyed a more or a less optimistic message and it also resulted in less likelihood of choosing the more optimistic physician for themselves and their family. Clinical trial information: NCT02498899.
Family companions’ involvement during pre-surgical consent visits for major cancer surgery and its relationship to visit communication and satisfaction.
Authors: Isenberg Sarina , Aslakson Rebecca , Dionne-Odom J Nicholas , Smith Thomas J. , Smith Katherine Clegg , Singh Sarabdeep , Wolff Jennifer L , Roter Debra
Published: November 2017

30

Background: While research has explored the role of companions (accompanying family members) in medical visits, studies have not examined companions’ involvement in pre-surgical visits. This study explored how companions’ presence impacts communication and satisfaction during pre-surgical visits to discuss major cancer surgery. Methods: Secondary analysis of 61 pre-surgical visit recordings with 8 surgical oncologists at an academic tertiary care hospital. Recordings were analyzed using the Roter Interaction Analysis System, and surgeons and patients completed a post-visit satisfaction questionnaire. Poisson and logistic regression models were used to assess differences in communication and satisfaction when companions were present (n = 46, 75%) and not present (n = 16, 25%). Models were fit using generalized estimating equations to account for nesting of patients within surgeons. Results: Companion communication was largely emotional and facilitative. In unadjusted analyses, companion presence was associated with a 29% increase in surgeon talk in the visit overall (IRR 1.29, p = 0.006), and a 41% increase in the amount of medical information provided (IRR 1.41, p = 0.001). Companion presence was associated with 45% less patient disclosure related to lifestyle/psychosocial topics (IRR 0.55, p = 0.037). In adjusted analyses, companions’ presence was associated with 23% lower levels of patient-centeredness (IRR 0.77, p 0.004). No difference between visits with and without companions in patient nor surgeon satisfaction. Conclusions: Companions’ presence increased the medical focus of the discussion; surgeons conveyed more medical information, and patients disclosed less psychosocial information. Companions might perceive patients as anxious prior to major surgery, compelling companions to advocate for the patient. Companion’s presence might be beneficial; however, this benefit might not be captured by the patient-centeredness ratio. As there was no difference in satisfaction, patient and surgeon satisfaction may not be predicated on patient-centeredness, but on the conveyance of timely, surgery-related information. Clinical trial information: NCT02489799.
A dynamic managed care platform for palliative care.
Authors: Fruth Briant , Fitch Tom R. , Shannon Robert P. , Uitti Ryan , Carey Elise , Ingram Cory , Tan Angelina D. , Alexander Alex , Warsame Rahma M. , Melanson-Arnold Margot , Sloan Jeff A.
Published: November 2017

32

Background: The link between patient concerns and clinical systems delivery is often suboptimal. We developed a case management system for palliative care which transforms the patient’s greatest concerns into actionable clinical pathways. Methods: The system collects patients’ single greatest and second greatest concern plus Quality of Life (QOL) data (pain, fatigue and overall QOL single-items scored 0-10 with 10 representing worst pain/fatigue, or best QOL) and produces a report to guide the physician and patient. The system presents ten “buttons” in a xylophone-like grid: Personal Relationships, Monitoring Health, Emotional Health, Money, Health Behaviors, Medication Troubles, Care Access, Work Worries, Physical Health and Care Planning. We performed a quality improvement study at Mayo Clinic sites. Results: 409 patients participated in at least one survey from 11/04/2015 to 9/22/2016 (620 total surveys). The most common Main Concern was Physical Health 265/620 (43%) followed by Monitoring Health (17%), Medication (8%), and Emotional Health, Money, and Health Behaviors (7% each), Personal Relationships (6%). Future Care Planning, Work, and Care Access/Coordination were rarely chosen ( < 5%). The most common Second greatest concern was Health Behaviors 73/409 (18%) followed by Physical Health (17%). 93/122 (67%) patients changed their greatest concern from baseline to subsequent visits. The mean QOL, fatigue and pain at baseline were 4.8, 6.0 and 4.8 respectively, indicating substantial clinically significant deficits. Post baseline mean scores improved by a maximum of 0.8, 1.1, and 0.9 points respectively, representing clinically meaningful effects. On average it took 8 minutes for patients to use the system. Conclusions: The system was quick and easy to utilize. The personal impact concerns (physical/emotional health, medications) were most often cited as the greatest concern, while care issues were de-emphasized by patients. Patients and physicians praised the system for making visits more efficient and raising issues that otherwise might not have been addressed. This system has the potential to improve patient well-being and clinical outcomes, as well as to reduce burden on clinicians and optimize case management activities.
Disagreements in surgical decision making for advanced cancer patients secondary to deficiencies in palliative care education.
Authors: Bateni Sarah , Canter Robert J. , Meyers Frederick J. , Galante Joseph M , Bold Richard J.
Published: November 2017

34

Background: Surgical decision making in advanced cancer patients requires careful thought and deliberation balancing the high risks with the potential palliative benefits. We sought to compare palliative care education and decision-making for palliative surgery among physicians who commonly treat advanced cancer patients. Methods: Practicing surgeons, medical oncologists, palliative care physicians and critical care intensivists from a large urban city and its surrounding areas were surveyed with a 32-item questionnaire consisting of a palliative care education survey and 4 clinical vignettes depicting patients with advanced cancer and symptomatic surgical conditions. Results: Of the 299 physicians surveyed, 102 responded with a response rate of 34.1%. Respondents reflected the demographics of the total cohort. Physicians reported minimal hours of palliative care education during residency (median 0, IQR 0-8), fellowship (median 0, IQR 0-20), and continuing medical education (CME, median 8, IQR 0-20). Surgeons reported the fewest hours of palliative care education during residency, fellowship, and CME combined (median 10, IQR 2-15) compared to medical oncologists (median 30, IQR 20-80) and intensivists (median 50, IQR 30-100), p < 0.05. 19.6% of surgeons reported receiving no palliative care education compared to none of the medical oncologists and 7.7% of intensivists. Analysis of physician treatment recommendations for the 4 clinical vignettes showed disagreement among physicians regardless of specialty. Absence of palliative care training was associated with recommending major surgical intervention more frequently compared to physicians with ≥40 hours of palliative care training (0.7 ± 0.7 vs. 1.6 ± 0.8, p = 0.01). Conclusions: Deficiencies in palliative care education persist and adversely impact quality of care. Recent national society recommendations for palliative care services are well founded given these deficiencies. Additionally, our findings highlight a sustained failure of the current postgraduate medical education system and the need for greater efforts system-wide in palliative care education across medical and surgical specialties.
Listening behind closed doors: Shared decision making between hospice nurses and cancer patients and caregivers.
Authors: Oliver Debra Parker , Wallace Audrey S. , Washington Karla , Demiris George , Clayton Margaret F. , Reblin Maija , Ellington Lee
Published: November 2017

41

Background: The philosophy behind hospice care recognizes the patient and family as a unit of care and embraces their role in decision making. Research has primarily focused on physician and patient decision making yet, most decisions made at the end of life are between nurses, patients, and family members. The majority of hospice care is delivered in patient homes and little is known about these interactions. The goal of this study was to evaluate the shared decisions within the home environment between hospice nurses and patients/family. Methods: A secondary qualitative analysis of audio recordings of visits by 65 home hospice nurses to cancer patients in 11 hospice programs was conducted. Recordings were transcribed and coded by two team members using a pre-established nine element model of shared decision making. Elements of the model included: Defining a problem and options, discussing risks and benefits, focusing on how the options relate to patient values, the patient’s or family member’s ability to follow through, the provider’s recommendation, clarification of the understanding of options, and a follow-up plan. Results: Hospice nurses worked with families on an average of four problems in a mean visit time of 30 minutes. The hospice nurses used all the 9 recommended elements of shared decision making during home visits with patients and families however, not all elements were used in every visit. The most commonly used element was defining a problem, and the least used element was the assessment of patient and family understanding of options. Conclusions: Decision making for those enrolled in hospice occurs between nurses and patients/families. While ultimately responsible for the decisions that are made, physicians have limited interaction with the patient and family in their natural setting. Hospice nurses on the other hand, experience the impact of decisions in the environment in which they are implemented. Hospice nurses are the physician’s eyes and ears behind the closed doors of the home and can be valuable partners as they work with families on critical decisions several times each week.
Does prognostic uncertainty affect discussions of prognosis? Lessons from a survey of hematologic oncologists.
Authors: Odejide Oreofe Olukemi , Cronin Angel M. , Earle Craig , Mack Jennifer W. , Tulsky James A. , Abel Gregory A.
Published: November 2017

45

Background: Although recent advances in cancer therapy have improved survival for patients with solid tumors, they have also increased the complexity of prognostication (Temel, JCO 2016). Prognostic uncertainty is particularly prevalent in hematologic oncology (LeBlanc, JOP 2014) and potentially a barrier to timely end-of-life (EOL) communication (Odejide, JCO 2016). Methods: In 2015, we mailed a 30-item survey to a national sample of hematologic oncologists randomly selected from the American Society of Hematology directory. The survey was developed through focus groups (n = 20) and cognitive debriefing (n = 5). We aimed to characterize respondents’ reports of prognostic discussions, as well as their timeliness and content. Results: We received 349 surveys from 48 states (response rate: 57%). Median time in practice was 25 years and 57% practiced in community settings. Overall, 60% reported discussing prognosis with “most” ( > 95%) of their patients. Those with < 15 years clinical experience (AOR = 0.54, 95% CI 0.31, 0.94) and those considering prognostic uncertainty to be a barrier to EOL care (AOR = 0.57, 95% CI 0.35, 0.92) were less likely to have prognostic discussions with “most” of their patients. When discussing prognosis, almost all (98%) reported typically having an initial discussion at diagnosis or during a period of stability; however, 18% reported either never readdressing prognosis or doing so only when death is clearly imminent. In terms of preferred terminology, 57% reported routinely having “general discussions of potentially curable disease,” while 43% preferred providing specific data such as percent chance of survival or median survival. Conclusions: The majority of hematologic oncologists in this large cohort reported discussing prognosis with their patients, but doing so qualitatively, focusing on whether cure is possible. About one-fifth reported not readdressing prognosis in a timely manner. These suggest that the prognostic uncertainty common with blood cancers fosters missed opportunities to convey what is known about prognosis. Given the growing difficulty in solid tumor prognostication, these data may foreshadow coming communication gaps for oncology as a whole.
Oncologists’ experiences with goals of care conversations.
Authors: Smith Cardinale B. , Solomon Rachel , Lin Jenny J. , Feder Shelli , Bickell Nina A. , Schulman-Green Dena
Published: November 2017

50

Background: ASCO guidelines suggest that patients with advanced cancer should have goals of care (GoC) conversations with their oncologists, yet only 37% report having them, often at the end of life. Describing oncologists’ experiences with GoC conversations is a crucial first step in tailoring communication training interventions. Methods: We conducted semi-structured interviews with oncologists at academic, community, municipal, and rural hospitals (n = 4) in New York and Connecticut. We analyzed data using interpretive description. Three coders developed a code key, independently and then jointly coded transcripts, and identified themes. Results: Oncologists (n = 21) were 67% male, averaged 46 years old (range 34-68) and 20 years (range 8-42) in practice, and 59% reported training in GoC. Sixty-nine percent were White, 23% Asian, and 8% Hispanic. Within oncologist narratives we identified generalizable facilitators and detractors to their practice of GoC conversations. Facilitator experiences included formal training in GoC discussions, a practice culture that supported GoC conversations (i.e. presence of specialty level palliative care), interactions with patients who they perceived to have realistic expectations, and good strategies for self-care and coping. One oncologist stated, “I can't cry or die with every patient because then I won't make it through the day.” Detractors included patient failure to understand cancer severity or treatment goals, younger patient age, and being the oncologist sought for second opinion. Oncologists described active patient participation, respect for patient beliefs and values, and achieving agreement on a care plan as elements of successful GoC discussions. An oncologist summarized, “People who are in the healthcare field think that goals of care are an immutable statement, but it’s not.... the way you can make an effective goals of care discussion, is to relate to their reality.” Conclusions: Multiple considerations impact oncologists’ experiences with GoC conversations. Tailoring communication interventions to address these concerns may increase rates of earlier and ongoing GoC conversations. Clinical trial information: NCT02374255.
Oncology providers, patients, and caregivers reflect: Applying "big data" for better supportive outcomes.
Authors: Haverfield Marie C. , Singer Adam , Lorenz Karl
Published: November 2017

59

Background: The development of “big data” methods offers an opportunity to more precisely predict patient outcomes. We explored physicians, patients, and caregivers’ perspectives about the use of predictive models in oncology practice. Methods: We conducted 12 patient, 12 provider, and 12 caregiver interviews (N = 36) from Stanford University outpatient oncology clinics. We queried participants about patient and family-centered applications of predictive models for prognosis, cost, and novel patient and family-centered outcomes. Two trained coders iteratively examined transcripts for consistent topics and used the constant comparative methods to establish themes and sub-themes. Results: Several overlapping themes emerged: 1) Outcomes of Interest, [provider] “Predictive information about side effects or adverse effects of treatment would be helpful”: 2) Barriers to Using Predictions, [patient] “If it seems too sort of set in stone, without…you know, everything has grey areas”; 3) Benefits to Using Predictions, [provider] “Some people…their cancer may be cured, but they live with these really horrible chronic illnesses and some people would say, ‘I would have rather have just died from my disease than be in this shape’; and 4) Communication Strategy, [provider] “I’m not even sure if I would bring up the models…I would kind of fall back on what I normally discuss with patients”. A theme specific to the provider group was 5) Accuracy of Model Information, [provider] “It’s hard to know whether to use in the clinical setting just the results of the model or whether you would really want to go down to the root level and actually access the raw data”. A theme specific to the patient and caregiver groups was 6) Privacy, [caregiver] “I would want to be able to have the patient authorize that”. Conclusions: There is consistency between provider strategies to communicate prognostic information and patients’ perceptions of how they would like prognostic information to be communicated to them. While providers are concerned with accuracy of predictive models, patients and caregivers are more concerned with privacy.
Improving advanced care planning in patients with metastatic cancer.
Authors: Mahmood Tallat
Published: November 2017

6

Background: Our group as a member of the Michigan Oncology quality Consortium (MOQC) participates in ongoing quality metric evaluations every spring and fall. Through this exercise we found we were performing low on the advance care planning (ACP) metrics. To address this we first realized we did not had a consistent place in the HER to document this. We created an ACP note and then worked on identifying a patient advocate and starting the ACP process. Methods: We first assessed our standard practice prior to joining MOQC and found we were entirely dependent upon the physician to initiate the discussion and often this was being done by the physician only at the time of disease progression. We then garnered the healthcare team to help with the process. The medical assistants (MA) would give the patient the DPOA/ACP forms with a brief explanation of the forms. This would be reiterated by the provider. On subsequent visits, the MA would ask the patient about the status of the form and if it had been filled out, and if not the nurse was flagged to call the patients . The physician assistant starting discussing the DPOA/ACP form in the chemo teach sessions. We then audited the charts of 100 patients’ after implementing the changes and compared them to our historic data from MOQC. Results: By implementing these changes we were able to increase our hospice enrollment from 47% to 66%; and our documented discussion of ACP went from 27% to 83%. However 25% of our patients still died in the hospital and we were consulted on only 50% of the hospitalized patients. Conclusions: Although we were able to improve referrals to hospice and increase discussion of ACP, there is still much work to be done. Despite the improvements we saw in the documentation of end of life discussions there was still a significant number of patietns who were admitted to the hospital at the end of life and who died in the hospital. One of the reasons could be the lack of communication with admitting providers as we were consulted in only 50% of those patients.
How do late-stage cancer patients join an early phase clinical trial? A qualitative investigation of the process.
Authors: Garrett Sarah Bracey , Koenig Christopher J , Dohan Daniel Paul
Published: November 2017

60

Background: Late-stage cancer patients (LSCPs) face complex choices as they exhaust standard treatment options, including whether to seek enrollment in an early phase (EP) clinical trial and how they may engage palliative care. Existing research describes patient-level decisional motivations, but less is known about the process by which patients arrive at decisions and the institutional barriers or facilitators that shape it. We investigate this process and the key barriers and facilitators for initiating an EP trial. Methods: We collected longitudinal, ethnographic data on 96 LSCPs from breast, genitourinary, gastrointestinal, lung, gynecology, and melanoma clinics at two large academic medical centers. We used constant comparative analysis to inductively identify factors that shaped patients’ paths towards or away from EP trial initiation. Results: Four key factors shaped patients’ pathways and help explain why most patients did not join a trial. These arose during two distinct periods. The first, “Setting the Stage,” concerned achieving both (a) patient and (b) physician interest in and support for the patient’s involvement in an EP trial. These achievements depended on the patient’s knowledge and opinions of experimental research, the physician’s awareness of relevant EP trials, and whether the physician considered the patient a good EP candidate, among other influences. The second period, “Securing an Experimental Seat,” concerned aligning (c) the availability of a specific EP trial with (d) the patient meeting the trial’s eligibility requirements. Disease progression, type and timing of past treatments, and dynamic trial enrollment windows all complicated this alignment. Despite the complexity of Securing a Seat, our data suggest that Setting the Stage was the more consequential period in terms of when patients exited the EP trial pathway. Conclusions: Patients’ priorities and decision-making are only one part of a multi-level process. LSCPs’ paths onto an EP trial depend not only on their making a particular decision, but also on relational, clinical and system-level conditions. This suggests that boosting EP trials participation requires interventions on multiple levels.
Patterns of radiation delivery in the last 6 months of life.
Authors: Wallace Audrey S. , Williams Courtney , Kvale Elizabeth Ann , Pisu Maria , Partridge Edward E. , Fiveash John B. , Rocque Gabrielle Betty
Published: November 2017

66

Background: The purpose of this analysis is to report patterns of radiation delivery at the end of life among older cancer patients. Methods: This was a retrospective cohort study of deceased Medicare patients age ≥65 with Stage IV cancer treated from 2012-2014 at 12 cancer community networks affiliated with an academic center in the Southeast, with available follow-up through 2015. Patients without Medicare coverage through 2015 were excluded. The outcome of interest was receipt of radiation in the last 6 months of life. Bivariate analyses for age group (65-69, 70-79, 80+), gender, Charlson comorbidity index (0, 1, 2+), cancer type (lung, GI, GU, H&N), and center volume (high = > 4000 cases/year) associated with receipt of radiation were performed. Results: 3688 patients met inclusion criteria; 700 (19%) received radiation in the last 6 months of life. In the radiation group (RT) & no radiation group (no-RT), median age at cancer diagnosis was 73 & 75 years, 41% & 45% were female, and 50% & 54% had Charlson comorbidity index of 2+. For the RT and no-RT groups, the cancer distribution was lung (39% & 33%), GI (15% & 26%), GU (7% & 9%), and H&N (6% & 5%); median time from diagnosis to death for RT and no RT was 449 & 400 days. Median time from last fraction of radiation to death was 84 days for the entire cohort; 27% of radiation was delivered in the last 30 days of life. On bivariate analysis, patients treated with radiation were more likely to be younger, Caucasian, have lung cancer, lower Charlson comorbidity score, and be treated at smaller volume centers(all p < 0.05). Conclusions: Among older terminally ill cancer patients who received radiation, > 25% received radiation in the last 30 days of life, which may reflect the challenges of prognostication in this cohort. Older patients were less likely to receive radiation, which may be indicative of barriers associated with receipt of treatment with increasing age.
Use of hospice services among Medicare beneficiaries with acute and chronic leukemias.
Authors: LeBlanc Thomas William , Olszewski Adam J.
Published: November 2017

68

Background: Studies show lower rates of hospice use among patients (pts) with hematologic malignancies. Our objective was to describe trends in hospice use and in quality measures for end-of-life (EOL) care among Medicare beneficiaries with leukemias. Methods: From the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database, we selected pts with acute (myeloid or lymphoblastic) or chronic (lymphocytic, myeloid, or myelomonocytic) leukemias diagnosed in 1996-2011 who died in 2001-2011. We identified hospice enrollment at death, duration of hospice enrollment, inpatient deaths, intensive care unit (ICU) admissions within 30 days of death, and chemotherapy use in the last 14 days of life. We summarized linearized trends by year of death using log-binomial regression, reporting average annual percent change (APC). Results: Among 38,038 leukemia pts (41% acute, median age 78 years) 81% died, after median 2.8 months from diagnosis (95%CI, 2.7-2.9) for acute and 49.1 months (95%CI, 47.9-50.1) for chronic leukemias. Among pts who died in 2001-2011 ( N= 23,941), 42% were enrolled in hospice at the time of death. This proportion significantly increased between 2001 and 2011, from 33% to 48% (APC +4.1%, P< .001), both for acute and chronic leukemias ( Pinteraction= .25). Median time on hospice was 8 days, and the proportion of pts with < 3 days on hospice increased from 20% to 24% between 2001 and 2001 (APC +1.2%, P= .05). Inpatient deaths significantly decreased from 54% to 39%, respectively (APC -3.2%, P< .001), but ICU use at EOL increased from 34% to 41% (APC +2.4%, P< .001). Chemotherapy use at EOL was more frequent in acute (17%) than chronic (6%) leukemia, and decreased for both (overall from 15% to 10%, APC -3.2%, P< .001). Conclusions: The use of hospice services among older pts with leukemia has increased, suggesting its wider acceptance over time. However, the increasing proportion of brief, terminal hospice admissions, and increasing rate of ICU use at EOL reflect persistent barriers to early enrollment in this population. Some measures of aggressiveness of care (inpatient deaths, chemotherapy at EOL) are lower in the community than previously reported from academic centers (El-Jawahri, Cancer 2015).