bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of an NP-based model of palliative care delivery within an oncology clinic.
Authors: DAmbruoso Sarah F. , Wenger Neil , Coscarelli Anne , Hurvitz Sara A. , Pietras Christopher , Nechrebecki Meghan , Kung Jennie , Callahan Rena Desai , Goldman Jonathan Wade , Peddi Parvin F. , Alexandra Drakaki , Skootsky Samuel A. , Walling Anne Margaret
Published: November 2017

163

Background: We initiated a nurse practitioner (NP)-based model of palliative care delivery embedded within an oncology clinic guided by a shared mental model (SMM) between palliative care, oncology, and psychosocial oncology clinicians in order to foster best practice collaboration and closed-loop communication between teams. These data represent processes and outcomes three years after initial implementation of the program. Methods: We evaluated program growth as well as advance care planning, hospice use, and utilization in patients with advanced cancer seen by the palliative care NP compared to patients receiving usual care from March 2014 to March 2017 at University-based oncology clinics. We developed a palliative care quality improvement tool integrating administrative and clinical data from multiple sources, including the electronic health record (EHR) and external hospices, using progressive methods of pulling data, such as natural language processing, in order to identify patients with advanced cancer and key process and end of life utilization measures. We used chi square tests to compare care received by the two groups. Results: There was good adoption of the intervention. The number of participating oncologists increased from 2 to 5 and the palliative care NP shifted from part-time to full-time after the first 1.5 years of implementation. Patients enrolled in the NP-based model of palliative care delivery were more likely to have a documented goals of care conversation (74.6% v. 9%, p < 0.01), to be referred for additional psychosocial support (52.5% v. 30.9%, p < 0.01), and to complete physician orders for life sustaining treatment (POLST) (20.3% v. 4.5%, p < 0.01). There was no statistically significant difference in advance directive completion (28.8% v. 23.5%). Among decedents, patients enrolled in the NP-based model were more likely to be enrolled in hospice (50.5% v. 29.1%, p < 0.01). There were non-statistically significant trends toward less hospital (4.6 days v. 5.6 days) and ICU use (1.0 day vs. 1.3 days) in the last 30 days of life. Conclusions: An NP-model of palliative care delivery within an oncology clinic led to important improvements in key palliative care processes and outcomes.
Demographics and disposition of patients in an academic outpatient palliative care practice.
Authors: Zarrabi Ali John , Armstrong Karen , Curseen Kimberly A. , Quest Tammie E.
Published: November 2017

166

Background: Outpatient PC clinics strive to improve value by improving quality of care for patients while reducing cost. Justifying investment in outpatient PC necessitates characterizing the demographics and disposition of the patients whom these clinics serve. We sought to detail our outpatient palliative care practice in an urban academic medical center in the Southeast to serve a model for other institutions building a financial case for outpatient palliative medicine. Methods: A retrospective analysis from 2014-2017 was conducted on clinical and administrative data from the outpatient supportive oncology cohort at an urban Southern academic center. We performed multivariable logistic regression, t-tests, and chi square analyses to assess associations among variables of interest for patients. Results: Of our outpatient palliative care cohort of 3137 patients, 151 identify as white (51%) and 1377 as black (48%). Among whites 140 (9%) expired and 91% went to hospice compared to 151 (11%) nonwhites expired and 89% nonwhites went to hospice. Furthermore, 21% of non-whites were enrolled in commercial insurance while 79% were enrolled in government insurance compared to 28% whites in commercial insurance and 72% enrolled in government insurance. There were significant correlations among race, age, length of stay (LOS), and discharge disposition (p < 0.05) and race and payer mix (X2= 17.67 df=2, p = .0001). White patients and older patients (P < 0.05) were more likely to enter hospice care compared with minority patients (t = -.655, P < 0.0001). Finally, 2942 patients (94%) received opioid pain medications, and over 90% had > 5 readmissions. Conclusions: In our academic outpatient palliative care clinic we found most patients had governmental insurance, most were prescribed opiates, and older patients and white patients had significantly greater LOS and hospice enrollment compared to black patients. These data illustrate the diversity, payer mix, and disposition to expect when building a case to develop an outpatient palliative care practice in an academic urban medical center.
Models of care for serious illness: What is the evidence?
Authors: Whitney Robin L. , Bell Janice , Nguyen Khue , Schmidt Theresa , Ozcelik Sibel , Matsumoto Cynthia
Published: November 2017

168

Background: Individuals with cancer and other serious illness may benefit from specialized models of care, including palliative care. However, limited evidence exists to guide real-world implementation of such programs. We reviewed evidence supporting models of care for serious illness as part of a larger effort to develop an implementation framework for serious illness care programs. Methods: We conducted a systematic review, focusing on existing reviews and meta-analyses across a broad range of serious illness population definitions and programs. The quality of evidence was graded and results were synthesized with respect to five outcomes categories (patient and caregiver experience; care and support processes; health outcomes; health service use and costs; and operations), program components associated with success, and implementation considerations. Results: Collectively, 28 reviews were identified, reporting 743 studies, 426 of which were randomized controlled trials. The strongest and most consistent evidence was for reduced health service use and costs (e.g., reduced hospitalization and emergency department use) and for improved patient and caregiver experiences. Few reviews reported on operational outcomes. Program components most frequently reported as associated with success included targeted selection of high-risk patients; face-to-face contact; and transition management. Common recommendations for implementation (reported in 10 of 28 reviews) included attention to relationship building, inclusion of technology-enabled decision support and continuous quality improvement. Conclusions: Compelling evidence exists for improved outcomes across a range of serious illness care models and populations with palliative care needs. Policy attention to payment structures that support feasibility and sustainability of these care models is warranted. Future research might address gaps in the literature, including implementation-related factors, operational outcomes and the relative contribution of individual components associated with program success.
Simultaneous Care clinic (SCC): A three-year monoinstituional experience.
Authors: Stragliotto Silvia , Brunello Antonella , Galuppo Sara , Murgioni Sabina , Dadduzio Vincenzo , Lamberti Evelina , Guglieri Irene , Schiavon Stefania , Nardi Maria Teresa , Procaccio Letizia , Zagonel Vittorina
Published: November 2017

169

Background: Early palliative care has been shown to improve outcomes in pts with advanced cancer. In accordance with ASCO and AIOM recommendations of implementing palliative care early for pts with metastatic cancer along with active cancer treatment a SCC was set up at Istituto Oncologico Veneto (IOV) in Padova since 2014; Methods: Data of pts referred to the SCC from Mar 2014 to Nov 2016 were retrieved from a prospectively maintained database. Data collected included cancer type, status of disease, PS, ongoing oncological treatment, psychological evaluation, social evaluation, nutritional evaluation, activation of home territorial services and/or Palliative Care services, use of other health services after a first visit and place of death; Results: 533 pts were evaluated by a multidisciplinary team. Overall symptom burden was low with baseline symptom scores highest for fatigue, lack of appetite and depression. Nutritional evaluation revealed 224 pts (42%) with nutritional problems, the most frequent being weight loss (n = 121). Psychological distress was present in 185 pts (35%). Social issues were present in 26 pts (5%) and were dealt with activation of social services (n = 9) or volunteer territorial services (n = 8). Patients deemed in need of home care services after the first access to the SCC were 177 (33%) and for these a formal request for Home Care services activation was sent to the Local Health Territorial Unit. After the first visit 141 patients referred to Emergency Room for intervening problems with median time of 41 days. Globally 290 pts (54%) died with 53% of deaths occurring at home. For pts who were receiving active oncological treatment median time from first-visit in the SCC and death was 126 days. We are also evaluating a score for priority for access to SCC; Conclusions: Early integrated SC may be most effective if targeted to the specific needs of each patient population
Impact of palliative care referral on hospice enrollment: A single center analysis.
Authors: Sinha Shreya , Basnet Alina , Syed Wajihuddin , Koparthy Pallavi , Khan Rashad , Madhira Bhaskara Reddy , Huang Danning , Lemke Sheila M.
Published: November 2017

17

Background: Despite ASCO’s recommendation to introduce palliative care services for all patients diagnosed with localized or metastatic pancreatic cancer, most patients’ care does not involve this multimodality approach. Transitioning patients to hospice at an appropriate time is essential in oncologic practice. The purpose of this study is to identify which variables affect acceptance of hospice services by patients. Methods: A retrospective chart review of patients with pancreatic cancer treated at Upstate University Hospital from 2011-2015 was performed. We studied variables including age, sex, race, stage, insurance status, advance directives, performance status and laboratory values. We analyzed patients based on acceptance or rejection of hospice care in their disease course and conducted a univariate analysis on different factors to determine predisposing variables. p-values were calculated using Chi-Square test and t-test. Results: We reviewed 325 patients charts and found statistically significant relation to acceptance of hospice and insurance status, and involvement of palliative care in their care. Patients with Medicare were more likely to decline hospice care whereas patients with Medicaid or no insurance were more likely to accept it. 36.23% of patients saw palliative care services at any point in their treatment course and these patients were more likely to accept hospice care than patients who did not (p = < 0.0001). Patients who were seen by palliative care earlier in their disease course were more likely to accept hospice care, although this did not reach statistical significance (p = 0.0731). Patients with stage IV disease were more likely to accept hospice care (p = 0.0095). Other variables like presence of advanced directives, tumor markers, age, and sex did not have a significant impact. Conclusions: Palliative care involvement is beneficial in patients with pancreatic cancer as they face a rough disease course with multiple treatment and disease related morbidities. Patients with early palliative care involvement during their illness are more likely to decide on hospice care at the end stages of their malignancies. This supports early palliative care introduction as an adjunct to oncologic care.
Development of a Prompt Radiation Oncology Mediated Palliative Treatment (PROMPT) program for handling urgent cases at an academic hospital.
Authors: Robbins Jared R. , Shukla Monica , Bedi Manpreet , Johnstone Candice Aitken
Published: November 2017

173

Background: Oncology inpatients frequently need urgent palliative radiation therapy (RT). Evaluating and treating these unscheduled patients adds challenge and stress to all members of the radiation oncology team. To efficiently and compassionately address these situations, and ensure prompt, evidence-based, quality treatment, we developed the PROMPT program. This included scheduling designated consult slots for emergencies, adding flexible CT simulation times, assigning palliative-specific dosimetrists, and engaging support staff to improve workflow. The purpose of this project was to evaluate the PROMPT program with various quality metrics and identify areas for further improvement. Methods: Patient data from inpatient encounters for academic year 2016-2017 (July 1, 2016 to June 30, 2017) were reviewed. The day of the consultation, reason for consult, date of simulations, and dose fractionation were recorded. Time from consult to simulation, and treatment initiation were calculated. Results: A total of 270 inpatient consults (199 new and 71 established) were evaluated. During the inpatient stay, 141 CT simulations and 121 verification simulations were performed. For those treated with palliative intent, 87% were simulated within one day of consult (72% same day, 15% next day). The median time from consult to the start of treatment was 1 day with 56% starting treatment within 1 day and 75% within 3 days. The most common reasons for RT were bone metastases (30%), brain metastases (19%), airway obstruction (15%), soft tissue masses (11%), and spinal cord compression (7%). For bone metastases, the median time from consult to end of treatment was 6 days with hypofractionated regimens being commonly employed in 86% (55% received 20 Gy in 5 fractions, and 31% received single fraction). Of those that started RT as inpatients, 13% stopped prior to completion, usually to enter hospice. Conclusions: The PROMPT program provided rapid identification of patients requiring palliative RT and an effective and efficient path from consultation to treatment. Implementing similar programs at other centers could facilitate improved care of palliative patients.
Effect of creative writing on mood in cancer patients.
Authors: Hussain Muhammad Azam , Zhu Junjia , Drabick Joseph , Joshi Aditya , Saunders Erika , Truica Cristina I. , Hayes Michael , Joshi Monika
Published: November 2017

178

Background: Patients with cancer may have significant mental health comorbidity. Creative writing has a substantial history in providing a wide range of psychological benefits for cancer patients. Methods: We conducted a pilot study to determine feasibility whether cancer patients can be enrolled, randomized and retained for four weeks for creative writing classes (Feasibility was defined as 50% of our enrolled patients on intervention arm (IA) could attend at least 2 classes). We anticipated enrolling 45 patients over the period of 2 months with randomization into 2 arms: IA and standard of care (SOC). “Write from the Heart”, a series of creative writing workshops (CWW) were conducted on IA. Subjects in IA had four, 2-hour weekly CWW whereas SOC arm did not receive any sessions. We used validated Emotional Thermometer Scales (ETS), ranging from 0 (best)-10 (worst), to predict changes in parameters reflecting patient’s mental health pre and post intervention. ETS has five dimensions (distress, anxiety, depression, anger and need help), which are all continuous variables. Results: Total of 16 patients were accrued -11 in IA and 5 in SOC. 7 out of 11 (63%) patients enrolled in IA attended at least 75% of classes. Comparisons were made using two-sample T-tests. Although sample size was small, analysis showed intriguing results. IA did show a decreasing pattern on Total Emotion Score (TES). For each visit, post-class scores were lower than pre-class scores. SOC versus IA and IA intragroup analysis (Paired T-test) did not reveal any statistical significance. Conclusions: We observed that it is feasible for cancer patients to attend focused workshops geared towards mental health wellbeing. Although not statistically significant, IA showed trend towards mood improvement. A second study is planned with a single arm for all cancer patients. In addition to using emotional thermometers, we will include questionnaires to evaluate mental health symptoms effectively. Further prospective clinical studies should be conducted to evaluate effect of this intervention in cancer patients. Clinical trial information: Study 00006541. [Table: see text]
Couple-based mind-body intervention for patients with metastatic lung cancer and their spouses.
Authors: Milbury Kathrin , Engle Rosalinda , Liao Zhongxing X. , Tsao Anne S. , Owens April , Bruera Eduardo , Cohen Lorenzo
Published: November 2017

179

Background: Given the incurable nature of metastatic lung cancer, patients and their spouses are at risk of experiencing psychological and spiritual distress. To address these concerns, we developed a couple-based mind-body (CBMB) intervention. This formative research aimed to examine intervention acceptability and initially efficacy in patients with metastatic lung cancer undergoing treatment and their spouses. Methods: We first conducted focus groups followed by a single-arm trial. Focus group participants completed program exercises and then semi-structured interviews and written evaluations including Likert-scale and open-ended questions. In the single-arm trial, the four intervention session were delivered over a 2-week period focusing on cultivating mindfulness, interpersonal connection, gratitude and purpose. Couples completed measures of depressive symptoms (CES-D), cancer distress (IES), spiritual well-being (FACT-Sp) and sleep disturbances (PSQI) before and after the program. Results: Focus groups (n = 7 dyads) revealed high acceptability ratings of the CBMB intervention (e.g., all participants would recommend the intervention). Consent and adherence rates (54% and 67%, respectively) were acceptable for the single arm trial (n = 7 dyads). All patients (67% male; µ age = 55 years) and partners (33% male; µ age = 59 years) rated the intervention as useful. Paired t-test analyses revealed large effects for sleep disturbances ( d= 1.83) and medium effects for cancer distress ( d= .61) for patients and large effects for depressive symptoms for spouses ( d= .90). Conclusions: Based on this two part study, the CBMB intervention appears to be acceptable and subjectively useful. There was also preliminary evidence regarding treatment gains for both patients and partners. A randomized controlled trial is warranted to further examine this supportive care strategy.
Lost in translation: Adolescents and young adults use words of hope to express their spirituality.
Authors: Barton Krysta S. , Tate Tyler P , Rosenberg Abby R.
Published: November 2017

185

Background: Adolescents and Young Adults (AYAs) with cancer are at risk for poor psychosocial outcomes, in part because cancer may disrupt developmental processes such as spiritual questioning. Indeed, spirituality may enable hope, meaning, and purpose, in turn facilitating the adjustment to cancer. The need to address spirituality has been established among adult patients, how to do so in an AYA age-appropriate manner has not been described. We aimed to better understand the language and perspectives of AYAs regarding spirituality. Methods: AYA patients (ages 14-25 years) were eligible if they had been diagnosed with cancer within the past 60 days. Demographic surveys including self-reported spirituality and religiousness were completed at the time of enrollment. Semi-structured, 1:1 interviews were conducted at the time of enrollment, 6-12, and 12-18 months later. Verbatim transcripts were coded by three independent coders using directed content analysis for instances of spirituality, religiosity, hope, and fear. Additional deductive analyses used a priori coding themes defined from prior conceptualizations of AYA hope: forced effort, personal possibilities, expectations of a better tomorrow, and anticipation of a better tomorrow Results: Seventeen patients completed 44 interviews with > 100 hours of transcript-data. Their mean age was 17.1 (±2.7); 8 (47%) were male, their diagnoses were sarcoma (n = 8), acute leukemia (n = 6), and lymphoma (n = 3). At enrollment 10 (58%) & 6 (35%) endorsed personal spirituality and religiousness in surveys, respectively, few verbal narratives included explicit self-identification of either construct. Further, while many AYAs denied spiritual beliefs, all of them endorsed hopes, often as a source of strength, meaning, or self-expression. Longitudinal analyses suggested an evolution of spiritual beliefs and self-identities, even when patients selected other language to describe such processes. Conclusions: AYAs with cancer are trying to work-through complex existential beliefs and questions. Often, instead of defining themselves as spiritual or religious or using explicit spiritual language, they articulate their existential feelings with the language of hope.
Engaging staff in advance care planning during National Healthcare Decisions Week at a major cancer hospital.
Authors: Emanuel Lindsay , Ito-Hamerling Gayle , Boutros Nicole , Zachariah Finly
Published: November 2017

19

Background: In a 2014 study of US adults, “lack of awareness” was the most commonly reported reason for not having an advance directive (AD). Medical staff have opportunities to increase AD awareness for patients at key touchpoints in the cancer treatment trajectory. At City of Hope National Medical Center (COH), the Department of Supportive Care Medicine with administrative support and significant institutional collaboration created a patient-and-staff-centric Advance Care Planning program and marketing awareness campaign titled “Plan Today for Tomorrow.” Methods: Efforts were made to increase staff comfortability with and personal completion of ADs. General education was provided through staff in-services, medical grand rounds, and new employee orientation, all with opportunities to complete personal ADs. In addition, education and training were provided to staff at key patient touchpoints, including new patient services and the pre-anesthesia testing clinic. Most recently, during the 2017 National Healthcare Decisions Week, one day was tailored specifically to increasing the number of staff who have completed their own advance directive. A five dollar Starbucks incentive was made available for non-physician staff who completed their own AD. Free notary services and AD support were made available at multiple locations on the main COH campus and satellites clinics. Results: On the day dedicated to staff outreach and completion of personal ADs during the COH 2017 National Healthcare Decisions week, 109 staff members completed their own AD. Staff participants reported increased comfort with the AD conversation, relief of personal burden by completing AD, increased understanding of the document and the importance of completion, and a sense of “practicing what they preach” to patients. Conclusions: Targeted efforts to engage staff in advance care planning can be successful. Nominal incentives may be helpful to attract staff to explore advance care planning personally. Further work is needed to embed advance care planning and advance directive completion in the culture of healthcare institutions.
Inclusion of spiritual pain in patient reported outcome assessments as part of an integrative medicine physician consultation.
Authors: Lopez Gabriel , Liu Wenli , Chen Minxing , Li Yisheng , Chaoul Alejandro , Bruera Eduardo , Cohen Lorenzo , Delgado-Guay Marvin
Published: November 2017

190

Background: Complementary and integrative health services are increasingly available to patients at cancer centers to help address physical and psychological needs. We review inclusion of spiritual pain (SP) as part of patient reported outcome (PRO) assessments in patients presenting for an outpatient integrative medicine consultation at a comprehensive cancer center. Methods: PRO data were collected as part of outpatient physician consultations at an integrative medicine clinic; we reviewed data between January 2013 and April 2017. Patients completed the Edmonton Symptom Assessment Scale (ESAS-FS, 12 symptoms, scale 0-10, 10 worst possible) immediately prior to the clinical encounter. ESAS distress subscales analyzed included psychological, physical, and global. Statistical analyses included summary statistics, two sample t-tests, correlations, and logistic regression. Results: We analyzed data from 4348 unique participants. Demographics included 65% women, average age 55.5, 78% Caucasian, 72% married or with significant other, majority Christian non-Catholic (49%) followed by non-specified (23%), and Catholic (20%). Overall, 41% of patients reported SP at baseline. Patients reporting a SP score of ≥ 1 (n = 1549) reported significantly higher levels of global, physical, and psychological distress than patients with SP scores of 0 (n = 2275) (all p’s < 0.001). Older patients and men were less likely to report SP. SP clustered with psychological symptoms of depression and anxiety (reliability coefficient 0.76). Conclusions: A significant number of cancer patients presenting for integrative medicine consultations reported having SP, with SP clustering with psychological versus physical symptoms. More research is needed to better understand how routine screening for SP contributes to assessments of overall psychological health.
A multimodal intervention to enhance sexual function and quality of life (QOL) in hematopoietic stem cell transplant (HCT) survivors.
Authors: El-Jawahri Areej , Fishman Sarah , Vanderklish Julie , Traeger Lara , Dizon Don S. , Temel Jennifer S.
Published: November 2017

191

Background: Although sexual dysfunction is a common long-term complication in allogeneic HCT survivors, interventions to address sexual dysfunction are lacking. Methods: We conducted a pilot study to assess the feasibility and preliminary efficacy of a multimodal sexual dysfunction intervention to improve sexual function in allogeneic HCT survivors. Transplant clinicians systematically screened all HCT survivors ≥ 3 months post-HCT for sexual dysfunction causing distress using the NCCN Survivorship Guidelines. Those who screened positive attended monthly intervention visits with trained study clinicians that focused on 1) assessing sexual dysfunction; 2) educating and empowering patients to address this topic; and 3) implementing therapeutic interventions. We used the PROMIS Sexual Function and Satisfaction Measure, Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT), and Hospital Anxiety and Depression Scale (HADS) to assess sexual function, QOL, and mood at baseline and six months post-intervention, respectively. Results: 33.1% (50/151) of patients screened positive for sexual dysfunction causing distress. 94.0% (47/50) of patients who screened positive agreed to participate. We demonstrated significant improvement in patients’ satisfaction and interest in sex as well as sexual function including orgasm, erectile function, lubrication, and vaginal discomfort [Table 1]. Six of ten patients who were not sexually active prior to the intervention became sexually active post-intervention (P = 0.031). Patients reported improvement in their QOL and a trend toward lower depression (Table). Conclusions: The multimodal intervention to address sexual dysfunction appears feasible with encouraging preliminary efficacy for improving sexual function, QOL, and mood in allogeneic HCT survivors. Clinical trial information: NCT02492100. [Table: see text]
Factors associated with lack of proper hydration in terminal cancer patients.
Authors: Bryniarski Pawel
Published: November 2017

195

Background: Dehydration is a frequent problem in patients suffered from terminal cancer. It decreases the quality of life and increases the amount of complications. The aim of our study was to determine factors connected with dehydration in patients with terminal cancer. Methods: 310 terminal cancer patients admitted to Palliative Care Unit were retrospectively analyzed. Detailed physical examination, medical history including history taken from family and care givers was taken upon admission. Laboratory parameters including morphology, concentration of sodium, potassium, total and ionized calcium, LDH were taken on admission. Univariate and multivariate logistic regression analysis were used to determine possible predictors, symptoms and consequences of dehydration. Results: On admission 34,51% of patients were dehydrated. They had more frequently: metastases (OR = Odds Ratio = 2,77, p = probability value = 0,019), nausea and vomiting (OR = 2,234,p = 0,0176), dyselectrolytemia (OR = 2,609, p = 0,0007); had higher PS scale note (OR = 1,458, p = 0,0031); were more often cachectic (OR = 2,482, p = 0,0003); had lower albumin level (OR = 0,931 ,p = 0,0008). They had 235% higher risk of death (OR = 2,356, p = 0,0007). Multivariate logistic regression analysis after adjustment for possible confounders reviled that occurrence of: metastases (OR = 2,665, p = 0,045), cachexia (OR = 2,105; p = 0,01) and nausea and vomiting (OR = 2,727, p = 0,026) remained independently associated with dyselectrolytemia. Conclusions: Occurrence of metastases, occurrence of nausea and vomiting and occurrence of cachexia are factors associated with dehydration. Patients with lack of proper hydration had 235% higher risk of death. Project "Extension of life and improvement of its quality and reduction of cancer patients' mortality due to proper control of water and electrolytes management and elimination of risk factors for dehydration and dyselectrolytemia" co-financed by the European Social Fund under the project of the Ministry of Science and Higher Education of Poland entitled "Best of the best! 2.0".
Palliative versus nonpalliative patients’ perceptions of the effect of alcohol consumption on clinical outcomes.
Authors: McFarlane Graham , Balaratnam Karmugi , Selby Peter , Alibbhai Shabbir , Brown M. Catherine , Jones Jennifer M. , Howell Doris , Pringle Dan , Xu Wei , Liu Geoffrey , Eng Lawson
Published: November 2017

199

Background: Little is known about the perceptions of palliative patients on the impact of continued alcohol consumption after a cancer diagnosis and whether they are similar to the perceptions of patients who are considered potentially curative. Methods: Patients with diverse cancer subtypes were surveyed at a comprehensive cancer centre, cross-sectionally. Specifically, palliative and non-palliative cancer patients were asked about their perceptions on the benefits/harms of continued drinking on cancer-related quality of life, fatigue, and overall survival, and whether they had received information on their alcohol consumption from their health care providers. Palliative status was established by chart review. Results: Of 1049 patients, 48% were male, with median age of 58 (18-98) years; cancer sites included gastrointestinal, genitourinary, breast, thoracic, hematologic, and others; 16% were classified as being palliative at the time of survey; and 14% reported receiving counselling information on alcohol use sometime after their cancer diagnosis. Compared to curative patients, palliative patients were more likely to perceive continued alcohol consumption as harmful to their fatigue (OR=1.39, P=0.05) and survival (OR=1.45, P=0.03), but less so on quality of life (OR=1.16, P=0.35). When compared to those who had not been counselled, informed patients were twice as likely (OR=2.01, P<0.01) to perceive continued drinking as harmful to their levels of fatigue, although there was less of a difference in their perception of quality of life (OR =1.39, P=0.20) and survival (OR=1.40, P=0.19). Conclusions: Palliative patients are more likely to perceive continued alcohol consumption as harmful to their fatigue and overall survival, when compared to non-palliative patients, especially after receiving counselling. Given the lack of data on the benefits or harm of mild-moderate alcohol use and a strong emphasis on quality of life, future research should focus on effects of alcohol in palliative patients, and there should be improved education to both providers and patients on regarding the current lack of information.
Patient-reported priorities for survivorship care and experience discussing available services.
Authors: Rabin Julia , Quain Katharine , Horick Nora , Chinn Garrett , McDonough Allison , El-Jawahri Areej , Chen Yen-Lin , De Rooij Belle , Perez Giselle Katiria , Park Elyse , Peppercorn Jeffrey M.
Published: November 2017

200

Background: Despite the recognized need for high quality survivorship care, barriers to identifying and addressing patients’ needs still remain. We sought to evaluate cancer survivor care priorities, awareness of available services, and factors associated with care and informational needs. Methods: A needs assessment survey was distributed to patients presenting for routine follow-up care in adult oncology clinics at the MGH Cancer Center between February and August of 2016. The survey assessed sociodemographic characteristics, and preferences for care and communication. Care priorities were selected from a list of options including open ended response. Discussion of supportive care services was assessed by the item “have any of your providers informed you about the types of supportive care services that are available to cancer patients" with response options of “yes,” “no” or “don’t know.” Results: Among 637 total respondents, 339 patients with early stage cancer completed the survey. The majority of participants were between 50-69 years old (54%), white (89%), female (64%), and college educated (80%). Breast (32%) and hematological malignancies (21%) were the most prevalent diagnoses. Commonly endorsed priorities for care included: emotional concerns related to cancer (40%), strategies to increase self-care (33%), and management of physical cancer symptoms (30%). Demographic and clinical factors associated with endorsing emotional concerns as a care priority included female gender, and moderate or greater levels of fatigue, depression, or anxiety (all p< 0.01). Factors associated with endorsing management of physical cancer symptoms as a care priority included younger age, and moderate or greater levels of fatigue or depression (all p≤0.01). Despite these priorities for care, only 41% of patients reported receiving information from providers about available supportive care services. Conclusions: Cancer survivors’ preferences for emotional support and symptom management are strongly associated with self-reported depression and fatigue. Routine screening for these issues and improvement in communication regarding available services should be prioritized in survivorship care.
Association between clinical and biochemical indices and survival in glioblastoma patients.
Authors: Liu Wenli , Qdaisat Aiham , Yeung Jason , Lopez Gabriel , Weinberg Jeffrey S , Cohen Lorenzo , Bruera Eduardo , Yeung Sai-Ching J.
Published: November 2017

201

Background: Survival of glioblastoma remains grim. Identifying survival-associating factors may provide actionable targets for future research and clinical intervention to improve patient outcomes. Our study examined the association between multiple clinical and biochemical indices and survival in glioblastoma patients. Methods: 265 consecutive glioblastoma patients who received tumor resection between 1/1/2010 – 12/31/2014 were reviewed. Data about treatments (extent of tumor resection, radiation therapy, and use of temozolamide), medical history, vital signs, weight, and lab tests were collected. Charlson Comorbidity Index (CCI) was calculated with ICD-9 codes. Lab and vital signs data within 30 days of surgery were excluded from the analysis. Cox regression for survival analysis was performed. Results: The mean age of the population was 57.5 years, with 78% death rate. The median survival was 19.1 months. Systolic blood pressure, blood glucose, and serum albumin were significant factors for survival while adjusting for known predictors, such as age, Karnofsky Performance Status (KPS), extent of tumor resection, and treatments (See Table). Conclusions: Optimization of medical comorbidities and nutritional status may have significant impact on the survival of glioblastoma patients aside from cancer specific treatments. The target range of systolic blood pressure, blood glucose, and serum albumin will need to be determined in future research. [Table: see text]
Integration of palliative care into oncology: A curriculum development project.
Authors: Von Gunten Charles F. , Periyakoil Vj , Brown Ally , Yzaguirre Ben , Spiegel Sam , Paris Andrew , Bender Stephen , Von Roenn Jamie H.
Published: November 2017

202

Background: Program Directors of Oncology Fellowships cite lack of adequate faculty to teach communication skills, prognostication and symptom management to oncology fellows as a barrier to ensuring oncologists integrate palliative care into their own practice. We partnered with ASCO and its Training Program directors to develop, evaluate and disseminate a PC curriculum using an innovative format. Methods: All of the fellows in a program were randomized as a single group to one of 3 cohorts: digital education, digital education plus a 4-week palliative care rotation or delayed digital education (control). In the intervention, each fellow received 2 MCQs (on their phones or other device) focused on a particular teaching point, every other day. If answered incorrectly, focused education material was forwarded to the learner and the testing point was retested at a later date. Fellows in cohort 2 also participated in a clinical rotation at an ACGME approved PC program. Cohort 3 received the same training as cohort one, but beginning fellowship year 2, as a delayed control. Fellows’ PC knowledge was assessed during the in-training exam pre- and post-intervention. Opioid prescribing behavior was tracked after graduation and compared with a control group( group 4). Results: 283 fellows from 71 programs were quasi-randomized. The average ITE score of PC MCQs ranged from 70-73% correct across all groups and all years, for pre- and post-test scores. All fellows randomized to the PC rotation, completed it. Prescribing data was based on NPI numbers and available for all providers. 72% of cohort 1 prescribed opioids appropriately, 57% cohort 2, 72% cohort 3, 46% in a group 4 (1 vs 4, p=.0008; 2 vs 4, p=.2231; 3 vs l, p=.0011). Conclusions: Spaced education via a hand held device is acceptable, efficient and cost-effective. All groups showed acceptable knowledge on the in-training examination. Yet, opioid prescribing behavior improved as a result of the education intervention. The favorable impact on opioid-prescribing behavior was extinguished by the PC rotation, raising the question about the role of a PC clinical rotation.
Risk of gastrointestinal and hepatic toxicities in patients with metastatic solid tumors treated with cabozantinib: A systematic review and meta-analysis of randomized controlled trials.
Authors: Zaw Myo , Thein Kyaw Zin , Han Myat M. , Igid Henry Palangdao , Hardwicke Fred L. , Tijani Lukman
Published: November 2017

208

Background: The vascular endothelial growth factor (VEGF) signaling pathways and the proto-oncogenes MET, KIT and RET were implied in cancer development and progression. Cabozantinib is an oral inhibitor of multiple tyrosine kinases and hence employed in many solid tumors. We performed a systematic review and meta-analysis of randomized controlled trials (RCT) to determine the risk of gastrointestinal (GI) and hepatic toxicities among patients with metastatic solid tumors treated with cabozantinib. Methods: MEDLINE, EMBASE databases and meeting abstracts from inception to March 2017 were queried. Phase 3 RCTs that mention GI and elevation of liver enzymes 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). Random effects model was applied. Results: We included 3 RCTs with a total of 1999 patients treated with cabozantinib for various solid tumors. The study arm used cabozantinib while the control arm utilized everolimus, placebo or prednisone. The relative risks (RR) of all-grade side effects were as follows: diarrhea, 2.39 (95% CI: 2.01 – 2.85, P < 0.0001); nausea, 1.86 (95% CI: 1.64 – 2.10, P < 0.0001); vomiting, 2.53 (95% CI: 1.60 – 3.99, P < 0.0001); stomatitis, 4.08 (95% CI: 0.55 – 30.01, P = 0.16); dysgeusia, 4.23 (95% CI: 2.30 – 7.76, P < 0.0001); elevated AST, 2.04 (95% CI: 1.12 – 3.73, P = 0.02); and elevated ALT, 1.61 (95% CI: 0.67 – 3.88, P = 0.28). The RR of high-grade side effects were as follows: diarrhea, 5.93 (95% CI: 3.43 – 10.25, P < 0.0001); nausea, 4.05 (95% CI: 1.99 – 8.23, P < 0.0001); vomiting, 2.37 (95% CI: 1.26 – 4.44, P = 0.007); stomatitis, 3.36 (95% CI: 0.45 – 24.98, P = 0.23); dysgeusia, 1.52 (95% CI: 0.15 – 14.57, P = 0.71); elevated AST, 1.70 (95% CI: 0.72 – 4.01, P = 0.22); and elevated ALT, 3.00 (95% CI: 0.60 – 14.93, P = 0.17). Conclusions: The risk of developing all-grade and high-grade diarrhea, nausea and vomiting with cabozantinib is high. Moreover, it is associated with all-grade elevated AST and dysgeusia. Timely recognition and providing good supportive care will enhance patients’ quality of life.
A systematic review and meta-analysis of randomized controlled trials to evaluate the risk of gastrointestinal and hepatic toxicities in patients with hormone receptor-positive HER2-negative metastatic breast cancer treated with CDK 4/6 inhibitors.
Authors: Zaw Myo , Thein Kyaw Zin , Tun Aung , Han Myat M. , Thar Yu Yu , Nayak Asha , Guevara Elizabeth
Published: November 2017

209

Background: Hormonal therapies function through CDK4/CDK6/E2F axis which is essential in luminal estrogen receptor positive breast cancer. Reactivation of these CDK4 and CDK6 kinases has been implicated in endocrine resistance. Many CDK 4/6 inhibitors were employed in studies with noteworthy safety concerns. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the risk of gastrointestinal (GI) and hepatic toxicities. Methods: MEDLINE, EMBASE databases and meeting abstracts from inception through June 2017 were queried. RCTs that mention GI symptoms and elevation of liver enzymes 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: We included five RCTs with a total of 2671 patients treated with CDK 4/6 inhibitors. The study arm used palbociclib-letrozole, palbociclib-fulvestrant, ribociclib-letrozole and abemaciclib-fulvestrant while the control arm used placebo in combination with letrozole or fulvestrant. The relative risks (RR) of all-grade side effects were as follows: diarrhea, 1.72 (95% CI: 1.08 – 2.74, p = 0.02); stomatitis, 2.62 (95% CI: 1.43 – 4.79, p = 0.002); nausea, 1.59 (95% CI: 1.30–1.94; p < 0.0001); vomiting, 1.65 (95% CI: 1.06–2.56; p = 0.02); elevated AST, 2.30 (95% CI: 1.34–3.93; p = 0.002); and elevated ALT, 2.78 (95% CI: 1.90–4.08; p < 0.0001). The RR of high-grade side effects were as follows: diarrhea, 2.26 (95% CI: 0.39 – 13.09, p = 0.36); stomatitis, 2.14 (95% CI: 0.36 – 12.72, p = 0.40); nausea, 1.13 (95% CI: 0.28 –4.47; p = 0.86); vomiting, 0.79 (95% CI: 0.24 – 2.54; p = 0.69); elevated AST, 1.85 (95% CI: 0.74 – 4.64; p = 0.18); and elevated ALT, 4.33 (95% CI: 2.15 – 8.71; p < 0.0001). Conclusions: The risk of developing any-grade diarrhea, stomatitis, nausea, vomiting and elevated AST and ALT, was high in CDK 4/6 inhibitors based regimen. Moreover, it increased the risk of high-grade elevated ALT.
Opioid epidemic or pain crisis? Exploring prescription opioid medication utilization for patients with cancer in rural Southwest Virginia.
Authors: LeBaron Virginia T. , Camacho Tareq Fabian , Russell Kyle , Beare Marianne , Gilson Aaron M.
Published: November 2017

210

Background: The U.S. is in the throes of two concurrent epidemics: too many people die from opioid-related fatalities, but too many people continue to suffer in pain. In certain regions this dilemma is particularly pronounced. For example, Southwest (SW) Virginia is a rural area with disproportionately high cancer mortality rates and high rates of opioid fatalities. Little is known about how to most effectively and safely manage pain in a region where there exists both a high cancer burden and significant opioid misuse. Purpose: Describe prescription opioid medication (POM) use for patients with cancer in SW Virginia and potential harms. Methods: This is a longitudinal, exploratory, secondary data analysis using the Virginia All Payers Claims Database (APCD), which includes paid medical and pharmacy claims data on 4 million individuals in the Commonwealth of Virginia. Patients with a diagnosis of cancer who lived in far, rural SW Virginia between 2011–2015 were included. Outpatient prescription data were linked to hospitalization admission claims data to explore potential opioid-related harms. Analysis was conducted at the patient, prescription and prescriber level (SAS 9.4, STATA 13.1) to identify predictors of POM use and opioid-related substance use admissions. Results: Within the APCD, POMs represent 7.23% of all medications prescribed for patients with cancer, with hydrocodone- and oxycodone-combinations, oxycodone, fentanyl transdermal patch and morphine sulfate being the most common. Over 50% of patients were prescribed a POM at least once during the study period. Multi-level logistic regressions suggest age, payer source, cancer type, gender, prescriber type and specialty were all significant (p < .001) predictors of being prescribed POMs. Preliminary analyses of hospitalized cancer patients found no association between POM use and opioid-related substance use hospitalization. Conclusions: A clearer view of geographic patterns and predictors of both POM use and potential harms can inform targeted clinical interventions and policy initiatives that achieve a balanced approach to POMs – ensuring access for patients in need, while reducing risk.