bluuebunny/crossref_metadata_2025 huggingface dataset:
End-of-radiation PSA as a novel prognostic factor in patients undergoing definitive radiation for prostate cancer.
Authors: Tran Phuoc T. , Narang Amol , Ram Ashwin , Robertson Scott P. , He Pei , Griffith Emiliy , Singh Harleen , DeWeese Tate , Honig Stephanie , McNutt Todd R. , Song Danny , DeWeese Theodore L.
Published: February 2017

68

Background: In patients with localized prostate cancer undergoing radiation therapy (RT) +/- androgen deprivation therapy (ADT), an end of radiation (EOR) PSA obtained during the last week of RT may serve as an early post-treatment predictor of poor outcomes and identify patients in whom to pursue treatment intensification or novel therapies. Methods: We reviewed an IRB-monitored, prospectively acquired database of patients with prostate cancer treated with definitive RT at our institution from 1993-2007 (n=890). Patients with an available EOR PSA were divided into two cohorts and analyzed separately based on inclusion of ADT into the treatment regimen. EOR PSA thresholds of 0.5 ng/mL and 1.0 ng/mL were explored. Multivariate analysis was performed to determine prognostic factors for biochemical failure-free survival (BFFS, Phoenix criteria) and overall survival (OS). Kaplan-Meier survival curves were constructed, with stratification by EOR PSA thresholds. Results: Median age was 69 years, with an even distribution of NCCN low risk (33.5%), intermediate risk (34.0%), and high risk (32.5%) patients. Median RT dose was 7020 cGy, and 54.5% were treated with ADT. Median follow-up of the entire cohort was 11.7 yrs. EOR PSA level was available for the majority of patients (77.5%). On multivariate analysis, EOR PSA >0.5 ng/mL was significantly associated with worse BFFS (p<0.0001) and OS (p<0.0001). In the subset of patients undergoing RT with ADT for NCCN intermediate/high risk disease, 5 yr BFFS was more disparate based an EOR PSA threshold of 0.5 ng/mL (5 yr BFFS: 87.3% vs. 41.1%, p<0.001), than initial NCCN risk level (5 yr BFFS: 88.7% vs. 76.9%, p=0.038). In NCCN low risk patients undergoing definitive RT alone, an EOR PSA threshold of 1.0 ng/mL was significantly prognostic of outcome (5 yr BFFS: 100.0% vs. 88.6%, p=0.024). Conclusions: For NCCN intermediate/high risk patients undergoing RT with ADT, EOR PSA >0.5 ng/mL may represent a better surrogate for poor outcomes than initial risk group. In addition, NCCN low risk patients undergoing RT alone who obtained an EOR PSA ≤1.0 ng/mL experienced excellent BFFS. Prospective evaluation of the utility of EOR PSA should be explored.
Simplified prostate lesion grading for magnetic resonance imaging and improved cancer detection at fusion-targeted prostate biopsy.
Authors: Kardos Steven V. , Nawaf Cayce , Fan Richard , Cornfeld Daniel , Weinreb Jeffrey , Schulam Peter , Sprenkle Preston
Published: February 2017

69

Background: Prostate cancer (PCa) is the most common solid organ malignancy in men and the second leading cause of cancer related death; however, it is the only tumor that is diagnosed by a non-targeted sampling method. Fusion targeted prostate biopsy is emerging as a more accurate way to detect PCa. The use of a multiparametric MRI (MP-MRI) with an endorectal coil (ERC) has traditionally been used, though the benefit for detection with ERC is controversial. In addition, there is significant heterogeneity in classification of MRI-identified lesions. We provide an initial report with fusion biopsy without an ERC and utilizing a simplified 3-point Likert scale for grading prostatic lesions. Methods: Patients underwent MRI-USG fusion biopsy for elevated PSA, abnormal DRE, or prior negative biopsy. Lesions visible on MRI were outlined in 3D and assigned increasing cancer suspicion levels using a simplified 3-point Likert scale by dedicated pelvic radiologists. The Artemis biopsy tracking system was used to fuse the MRI with real-time ultrasound. Using the 3D model, a 12-core systematic biopsy, as well as a targeted biopsy of suspicious areas, was performed by a urologist (PS). Results: 190 patients underwent MRI and fusion biopsy between 12/2012 and 8/2014. The overall cancer detection rate (CDR) for systematic biopsy was 52.3% and the CDR for fusion biopsy was 55.0%. However, the CDR for clinically significant PCa with systematic biopsy was 28.7% and for targeted biopsy was 43.8% (p=0.02). Evaluation of cancer suspicion level for each ROI revealed that patients with high suspicion scores had a higher overall CDR (p<0.0001) and higher risk of detecting clinically significant cancer under the Cochran Armitage Trend test (p=0.0001). Conclusions: MRI-USG fusion prostate biopsy using MP-MRI without an ERC and a read using a simplified 3-point Likert scale demonstrate improved detection of clinically significant PCa compared to a systematic 12 core TRUS biopsy, and further demonstrate that lesion suspicion correlates with CDR. CDR and lesion stratification are comparable to the published literature when using methodologies that may be more practical in a larger number of medical centers.
Feminization of the workforce in urologic oncology: Socioeconomic, workforce, and quality-of-life issues.
Authors: Pruthi Nicholas , Spencer E. Sophie , Lyons Matthew , Greene Peter , Nielsen Matthew Edward , Pruthi Raj , Raynor Mathew , Wallen Eric , Woods Michael , Smith Angela
Published: February 2017

72

Background: In recent years, the proportion of women in urology has been increasing, from <0.5% in 1981 to approximately 10% today. Nearly 25% of students matching in urology are now female. Our objective was to characterize the female workforce in urologic oncology and compare income, workload, and job satisfaction to the male counterpart and a non-oncology career. Methods: We queried the American Urological Association (AUA) domestic membership of practicing urologists regarding socioeconomic, workforce, and quality of life issues. A total of 6,511 valid survey invitations were sent via e-mail, and 848 responses were collected for a total response rate of 13%. Results: The percentage of females in the urology workforce is 11%, and only 4% of urologists with an oncology focus are female. Of those with a primary focus that is non-oncology, 13% are female. Demographics, income, and practice characteristics between these groups are shown in the Table below. Conclusions: Females appear to be relatively under-represented in urologic oncology, with lower income among women both in oncology and non-oncology fields. [Table: see text]
Combination external beam and brachytherapy for intermediate- to high-risk prostate cancer: Comparison of high-dose rate (HDR) and seed (LDR) implant methods.
Authors: Daniel Sarah E. , Carion Thomas , Schervish Edward , Frontera Rene , Aref Amr M. , Browne Cynthia Holland , Campbell Todd , Chuba Paul J.
Published: February 2017

90

Background: Maximizing the therapeutic ratio for intermediate to high risk localized prostate cancer may be accomplished by using a combination of external beam radiotherapy (EBRT) and radiation implant. Differences in implant methods could be expected to influence mortality. We compared outcomes for patients treated using combination EBRT and high dose rate (HDR) versus EBRT and low dose rate (LDR) seed implant methods. Methods: Between 12/1993 and 05/2010 there were 307 cases of combination therapy with analyzable data: 227 HDR + EBRT (HDRe) and 81 LDR + EBRT (LDRe) Intermediate risk patients had 1+ risk factors: PSA ≥ 10, Gleason score (GS) ≥ 7, or AJCC clinical stage ≥ T2b. High risk patients exhibited either 2+ of these risk factors or PSA ≥ 20, GS ≥ 8, or AJCC clinical stage ≥ T3. External beam radiation was 45 Gy in 1.8 Gy daily fractions using 3D conformal or IMRT methods. The prostate, seminal vesicles, and (in some patients) pelvic lymph nodes were treated. HDR brachytherapy was delivered one week prior to beginning EBRT. Afterloading HDR catheter needles were surgically implanted into the prostate. HDR dose was 21 Gy in three equal fractions of 7 Gy peripheral dose given over two days. LDR was performed 2-3 weeks after EBRT using I-125 or Pd-103 seeds and 109 or 90 Gy respectively. PSA failure was defined as “nadir plus two.” Results: HDRe and LDRe cases were well matched for pretreatment risk factors. There were 18 PSA failures in the HDRe group (7.9%) and 6 PSA failures in the LDRe group (7.4%). Adjusted Cox proportional hazard models showed no statistically significant difference between the treatment groups with regard to PSA failure. Hazard ratio for LDRe compared to HDRe was 0.82 (95% CI 0.28, 2.46; p=0.73). There were 26 deaths from any cause (11.45%) in the HDRe group and 11 deaths from any cause (13.58%) in the LDRe group. Adjusted Cox models showed no statistically significant difference between the treatment groups for survival. Hazard ratio for LDRe compared to HDRe was 1.49 (95% CI 0.68, 3.25; p=0.32). Conclusions: There were no statistically significant differences in PSA failure free survival or overall survival detected in LDRe versus HDRe patient groups.
A community-based approach to educating black men in underserved communities about the risks and benefits of prostate cancer screening.
Authors: Kennedy Mark Wendell , Carter Jacques , Wright Stephen , Contreras Magnolia , Winkfield Karen Marie
Published: February 2017

99

Background: Black men have the highest incidence of prostate cancer (PCa) and are twice as likely to die of the disease than any other race/ethnic group in the United States. The recent controversy related to PCa screening may disproportionately impact black men who are already at greatest risk from the disease. This project sets out to develop culturally-competent educational and screening programs for men in high-risk populations so they can make an informed decision about PCa screening. Methods: A community-based education and screening program targeted towards black men living in an under-resourced community in Boston, MA was implemented. A mobile PCa screening van was initially employed and stationed at a local community health center (CHC) twice annually. Education about PCa screening was provided by a trained racially-concordant patient navigator (PN). Screening was available on the van by a primary care physician (PCP). In 2013, the pre-screening educational model was incorporated into the clinical practice of a single PCP practicing at the CHC. Every male patient over the age of 40 had an educational consultation about PCa screening with the PN before seeing their PCP. The patient would then discuss screening with the doctor and decide whether to proceed at that visit. Results: From 2004 to 2013, 20 van visits were conducted at the CHC. Two-hundred seven (207) men received PCa screening education; 179 (86.5%) elected to undergo screening. Of the men screened, 26 (14.5%) were referred for further testing as a result of their screening test. From January 2013 to September 2014, 121 men received PCa education; 100 men (82.6%) were screened. Ninety percent had both prostate-specific antigen testing and a digital rectal exam. Conclusions: These data suggest that formal PCa screening education prior to meeting with a physician is welcomed and may be a way to increase baseline screening in high risk populations. This provides an opportunity to develop an individualized prostate health management program based on individual risk profiles and to carefully monitor PSA fluctuations. The ultimate goal is to reduce unnecessary interventions while capturing PCa early in men at greatest risk.
Disparities in the availability of and access to antiemetics recommended by the international antiemetic guidelines in Serbia, Japan, and Nepal.
Authors: Bosnjak Snezana , Zilic Ana , Gyawali Bishal
Published: February 2017

117

Background: Guideline-consistent antiemetic therapy requires 4 classes of antiemetics (AEs) to be available and accessible for the optimal prevention of chemotherapy induced nausea and vomiting (CINV): serotonin3 receptor antagonists (5HT3RAs), neurokinin 1 receptor antagonists (NK1RAs), dopamine receptor antagonists (DOPRAs) and dexamethasone. To evaluate disparities in the availability and accessibility of AEs recommended by the international antiemetic guidelines for the prevention of CINV inpatients treated in governmental hospitals in Nepal (low), Serbia (upper-middle) and Japan (high-income). Methods: Availability was evaluated by the formulary availability and marketing authorization (MA) in Serbia (RS), Japan (JP) and Nepal (NP). Accessibility was assessed by the National Health Insurance Fund (NHIF) coverage in Serbia and Japan and by the affordability in Nepal. Off-label use of medications is not legitimate in Serbia and Japan. Results: Barriers are presented in Table. Serbia has no access to NK1RAs and palonosetron for the prevention of CINV after HEC-AC and carboplatin. There are no barriers in Japan to provide all 4 classes of AEs. In Nepal all AEs are payed out of pocket and the guideline implementation completely depends on the affordability. Olanzapine is accessible in Nepal, but not in Japan and Serbia due to restricted off-label use of medications. Conclusions: The real life implementation of antiemetic guidelines for the prevention of CINV in various countries depends on the availability of and access to AEs recommended by the guideline. Identified barriers in Serbia and Nepal preclude physicians from providing optimal supportive care. [Table: see text]
Evaluation of patient's versus hematologist/oncologist's office visit agenda.
Authors: Patrick Cory , McIntyre Kaitlin , Singal Rakesh , Hansra Damien Mikael
Published: February 2017

125

Background: Few studies have been reported in oncology regarding elements of physician agenda. We aim to compare elements of a doctor office visit agenda between hem/onc physicians (MD) and patients (pts). Methods: Pts and MDs were enrolled to completed a five question survey. Pts were asked: “My doctor” Focuses more on quantity of life and less on quality of life, spends enough time with me, addresses symptoms, addresses chemo side effects, and addresses prognosis. MDs were asked the same questions but worded: "I” spend enough time with pts for example. Answers were recorded on a 5 point scale (1 = highly disagree, 2 = disagree, 3 = neutral, 4 = agree,5 = highly agree) and converted into 2 categories (1,2,3 = neutral/disagree vs 4,5 = agree). Fisher’s exact test with 2 sided p-value was used to compare significance between MD & pts. Results: 1008 pts and 55 MDs were enrolled between 06/2013 - 10/2015. Pt mean age 55 (18-88) with 45% male and 55% female. Racial profile: 16% white, 14% black, 2% Asian/Pacific Islander. Ethnicity: 62% of pts were Hispanic vs. 38% not Hispanic, & 6% other. A significant number of pts feel MDs focus more on quantity of life vs. quality of life (64% pt vs 26% MD p < 0.0001) and MD spend enough time (94% pt vs 82% MD p < 0.05). No differences were seen for symptoms (92% vs 87% p = 0.2), side effects (92% vs 94% p = 1.0), or prognosis (91% vs 96% p = 0.3) pt vs MD respesctively. Conclusions: Pts feel MDs focus more on quantity of life vs. the quality of life. MDs feel they focus more on quality of life vs. quantity of life. Perhaps bridging the gap in what constitutes “quality of life” may improve patient satisfaction. Furthermore MDs underestimate the time spent with their patients. Perhaps MD are spending too much time with some patients resulting in inefficient office visits.
Contribution of polypharmacy and potentially inappropriate medication use to inferior survival in older patients with aggressive lymphoma.
Authors: Lin Richard Jirui , Guo Robin , Becker Daniel Jacob , Grossbard Michael L. , Magid Diefenbach Catherine S.
Published: February 2017

129

Background: Survival outcomes for older patients with aggressive non-Hodgkin’s lymphoma (NHL) are disproportionally inferior to those of younger patients. While differences in tumor biology may play a role, older patients are often frail with comorbidities, polypharmacy, and use potentially inappropriate medications (PIM). Methods: Using Cox proportional hazard and logistic regression models, we retrospectively analyzed all aggressive NHL patients age 60 and older diagnosed and treated at our institution from 2009-2014 to examine the effect of polypharmacy and PIM use on progression-free survival (PFS), overall survival (OS), and treatment-related toxicities. Results: We included 141 patients with evaluable data after excluding patients with incomplete record. The median age was 71 years. At the time of diagnosis, 44% of patients used more than 4 medications and 47% used at least one PIM. During first-line treatment, only 43% of patients received chemotherapy of adequate relative dose intensity (>85% scheduled dose), and 63% experienced grade 3 or greater toxicities. Age, International Prognostic Index, and PIM use correlated with each other. Number of medications (p = 0.005) and PIM use (p < 0.001) were associated with shortened PFS by log-rank test, and PIM use remained a strong independent predictor of PFS in multivariable analysis (HR 1.84, p = 0.005). Number of medications (p = 0.003) and PIM use (p = 0.009) were also associated with shortened OS by log-rank test, although only albumin level predicted OS in multivariable analysis. Most importantly, PIM use was strongly associated with grade 3 or greater toxicities in multivariable analysis (OR 7.4, p = 0.001). Conclusions: We report here for the first time adverse impacts of polypharmacy and PIM use in older patients with aggressive lymphoma. We suggest that drug-drug interactions may significantly impair the delivery of adequate chemotherapy dosage and increase toxicities thus resulting in inferior survival outcome. Our findings support the use of evidence-based geriatric and palliative care principles to guide meticulous medication management to eliminate outcome disparity in older lymphoma patients.
Impact of cachexia at diagnosis on radiotherapy utilization and survival in non-small cell lung cancer.
Authors: Lau Steven , Giap Fantine , Gannavarapu Bhavani S. , Iyengar Puneeth
Published: February 2017

133

Background: The presence of cachexia at the time of cancer diagnosis and its influence on disease management and treatment outcomes for patients receiving radiotherapy are poorly described. Here, we assess the role of baseline cachexia in patients with NSCLC on first-line treatment modality and clinical outcomes. Methods: Retrospective review of medical records identified 1,334 patients with NSCLC consecutively treated at a tertiary care health system between 1/1/06 and 12/31/13. Cachexia was defined using the well-accepted and validated international consensus definition. The delivery of radiotherapy and its treatment intent were abstracted. Results: The cohort included a representative group of patients with a median age at diagnosis of 64 years, 47% females, and 32% patients of non-White race. Stage at diagnosis was I, II, III, and IV in 291, 105, 356, and 578 (43.3%) patients, respectively. Cachexia was present at the time of diagnosis in 403 (30.2%) patients including 18%, 14%, 32%, and 39% of stage I, II, III, and IV patients, respectively. Palliative intent radiotherapy was received by significantly more stage IV patients with cachexia (74%) than without cachexia (63%) (X2, P = .01). In contrast, baseline cachexia was not associated with curative intent radiotherapy in stage I-III disease. At a median follow-up of 24 months, 857 deaths have been observed. Cachexia at the time of diagnosis was prognostic for worse survival by stage. For patients with stage IV NSCLC, median survival was 11 months for patients without cachexia but 6 months for patients with cachexia at diagnosis (P < .001). Cachexia remained significant in stage I NSCLC, with median survival of 45 and 67 months with or without cachexia at diagnosis, respectively (P = .03). Conclusions: Cancer cachexia at the time of diagnosis is common in patients with NSCLC even with early stage disease. The presence of cachexia at diagnosis is associated with utilization of radiotherapy as a palliative treatment. However, cachexia at diagnosis of NSCLC, even with early stage disease, is prognostic of worse outcomes despite curative intent radiotherapy.
Pilot study of incorporating a supportive care program into a small community oncology practice.
Authors: Kalstrom Karly , Schultz Kelly , Thompson Jennifer , Byrne Michael Thomas , Buresh Andrew J. , Curley Brendan F.
Published: February 2017

149

Background: Incorporation of supportive care has become standard of care in patients with advanced or metastatic cancer undergoing palliative chemotherapy. Implementation of a supportive care program is often difficult in a small community practice due to a multitude of factors. Methods: We piloted a supportive care program with the partnership of Sage Hospice & Palliative Care in which patients with advanced or metastatic cancer undergoing chemotherapy would be evaluated by a certified nurse practitioner (CNP). Patients were selected for evaluation based on age, stage of cancer, and likelihood of needing additional supportive measures during their oncologic treatment. Patients were enrolled in the program by seeing the CNP and being followed throughout their chemotherapy, or until their death. Home visits were done by the CNP after hours, on weekends, or during business hours if it was noted to be medically necessary. Results: Forty-four patients were enrolled in the supportive care program. All patients either had metastatic or advanced cancer that required chemotherapy. The most common diagnoses are breast, pancreatic, prostate and lung cancer. The average number of patient home visits was 3.35 visits. Interventions varied, but the most common tasks performed were IV hydration, pain control and symptom management. Of the 44 patients, only 7 required an inpatient stay (15.9%) and none of these patients required a second hospital stay or were noted to be a 30 day readmission. Ten patients were enrolled in hospice, and 7 of those patients died. Zero patients died while on treatment or died without being enrolled on hospice. Conclusions: Incorporation of a supportive care program is feasible in a small community practice. The benefits may include improved patient outcomes, decreased hospitalizations, and smoother transition to end of life care.
Influence of early-phase clinical trial enrollment on patterns of end-of-life care for children with advanced cancer.
Authors: Ananth Prasanna Janaki , Monsereenusorn Chalinee , Ma Clement , Al-Sayegh Hasan , Wolfe Joanne , Rodriguez-Galindo Carlos
Published: February 2017

151

Background: Early phase clinical trials are critical to enhancing therapies for children with advanced cancer. However, trial enrollment may intensify end-of-life (EOL) care. We evaluated patterns of EOL care for patients at a large cancer center. Methods: Single-center, retrospective cohort study of pediatric oncology patients, ages 6 months-21 years, who died in 2010-2014. We queried electronic medical records to assess frequencies of medical procedures (e.g. intubations), clinic visits, and hospital admissions in the last 6 months of life. We assessed timing of pediatric palliative care (PPC) consultation, initial advance care planning (ACP) discussion, and entry of do-not-attempt resuscitation (DNAR) orders in the chart, in relation to date of death. Patients enrolled in early phase clinical trials for at least 1 cycle (EP) were compared with those not enrolled (NEP), using Wilcoxon rank sum and Fisher exact tests. Results: For N = 125 patients, median age at death was 11.6 years (IQR 5.8-16.3); 46% were female; 70% were White, non-Hispanic. 26% were trial enrollees. Diagnoses included 42% solid tumors, 41% brain tumors, and 18% hematologic malignancies. Most patients had PPC consultation (83%), ACP discussions (91%), and DNAR orders (86%). EP and NEP cohorts did not significantly differ in baseline demographic or clinical characteristics, frequencies of medical procedures, or hospital admissions. EP patients had a higher median number of clinic visits than NEP patients (18.5 [16.3-27.2] vs. 14.1 [6.5-20.7], p = 0.0003) and received PPC consultation significantly closer to death than NEP patients (median days before death = 58 [16-84] vs. 85 [32-173], p = 0.04). There was no difference between EP and NEP patients in timing of initial ACP discussion or of DNAR order entry. Conclusions: Near the EOL, EP patients had more frequent clinic visits and later PPC consultation, but trial enrollment did not appear to delay ACP discussions or increase hospital resource use. These results suggest that early phase clinical trial enrollment does not substantially alter EOL care patterns for children with advanced cancer.
Implementing an emergency department EMR trigger tool for palliative medicine consultation and its effect on length of stay and health care costs: A retrospective study.
Authors: Kozhevnikov Dmitry , Rivera Felix , Edwards Wendy
Published: February 2017

167

Background: Several studies have shown that palliative medicine consultation can improve multiple patient-centered outcomes, especially when provided early. Our goal is to show that our electronic health record (EHR) trigger tool is a cost-effective way for hospitals to identify patients who may benefit from early consultation, improving outcomes such as hospital length of stay and facilitating appropriate disposition for patients with metastatic cancer. Methods: Retrospective chart review of 721 patients at an urban community hospital who were identified by a trigger system integrated into the Emergency Department (ED) EHR. Patients who met criteria for a palliative consultation as determined by ED physicians at the time of inpatient admission were tracked by the palliative medicine department as part of a pilot phase. Those that were triggered and received usual care made up the control group. The intervention group was made up of patients who were triggered and seen in consultation. Results: Patients who were seen within 3 days of trigger were found to have a mean length of stay of 7.57 days, while those seen after 3 days had a mean length of stay 10.61 days. Patients who were triggered for metastatic cancer were found to have differences in final disposition between the two groups. Discharge to subacute rehabilitation facilities (SAR) in these patients decreased from 24% in the control group to 12% in the intervention group, while use of home hospice more than doubled to 11%. The percentage of these patients dying in the hospital decreased from 18% to 12%. Conclusions: Our study showed that earlier consultation was associated with shorter hospital length of stays if patients were seen within 3 days of being flagged as having palliative care needs in the ED. We also found that our EHR trigger doubled home hospice utilization in patients with metastatic cancer, decreased the proportion of discharges to SAR, and decreased in-hospital death in these patients.
Development and implementation of a clinical pathway for radiation of bone metastases on a palliative radiation oncology service.
Authors: Rotenstein Lisa , Killoran Joseph , Balboni Tracy A. , Krishnan Monica Shalini , Taylor Allison , Martin Neil E.
Published: February 2017

170

Background: Clinical pathways increase compliance with treatment guidelines and reduce in-hospital complications. Evidence around treatment of complicated bone metastases is increasingly nuanced and although ASTRO/ACR recommend single fraction radiation therapy for uncomplicated bone metastases, implementation is variable. We sought to determine the effects of a bone metastases-focused clinical pathway on the practice patterns of our institution’s palliative radiation oncology service (SPRO), which sees 600 patients yearly and on a rotating basis, involves 23 physicians, 28 residents, 2 nurse practitioners, and 1 fellow. We hypothesized that pathway implementation would augment data-driven use of palliative radiation for bone metastases, including use of 8 Gy x 1 for uncomplicated metastases. It would also enhance physician efficiency and confidence. Methods: Using published literature, clinical guidelines, and expert input, we designed a comprehensive clinical pathway for bone metastases radiation. This was translated to a secure electronic interface as a decision support tool and integrated into daily SPRO workflows. Providers were surveyed pre and post implementation to assess expectations and elicit feedback. Rates of pathway compliance and reasons for non-compliance were assessed. Rates of 8 Gy x 1 use for uncomplicated metastases were compared pre and post implementation. Our aim was for approximately 70-80% on-pathway rates. Results: The final pathway, which includes twenty endpoints, integrates several validated scoring systems, including assessments of life expectancy, spinal stability, and appropriateness of surgical management. The pathway has been well received on the SPRO service, with addition of extra steps to workflows being the main cause of resistance to use. Data on rates of pathway adherence will be reported, and rates of 8 Gy x 1 use will be compared to the baseline of 22%. Conclusions: Our experience suggests the utility of pathways-based decision support for bone metastases radiation on a palliation consult service. Next steps include assessing the pathway’s effects on guideline-concordant care and calculating associated cost savings.
Development and validation of the clinician palliative perception scale (CPPS).
Authors: Wong Aaron Kee Yee
Published: February 2017

179

Background: Worldwide healthcare systems identify a need to provide better evidence based service models for palliative care. There is little data and no standard tool that informs clinicians’ perceptions on palliative care to identify areas for service improvement and education. We aimed to develop and validate a tool to determine perceptions of hospital staff on palliative care provision, self confidence in providing palliative care, and predictors and barriers to requesting assistance. Methods: 604 hospital clinicians were recruited in person and online from a large metropolitan public tertiary teaching hospital network involving 5 campuses and 2 medical schools. They completed the CPPS (Clinician Palliative Perception Scale). Principal components analysis, exploratory factor analysis, and logistic regression were performed to examine the factor structure and relationship to clinical practice. Results: Four factors were extracted: confidence in providing palliative care, requesting assistance, global perceptions on palliative care provision, and barriers to referring. Increased confidence was significantly associated with increased likelihood of referring or requesting assistance and also associated with a good global perception on palliative care provision. Confidence was also significantly associated with years of experience and with spending > 50% time looking after dying patients. Good perception of palliative care provision was highest among oncologists. Conclusions: This is the largest quantitative study ever done looking at perceptions of palliative care provision among health professionals. The CPPS is a valid and reliable tool useful for both practice and research. Its 4 identified constructs are consistent with literature on perceptions and utilisation of palliative care services. Barriers to referring involved misconceptions that palliative care would prematurely shorten patient lifespans. Others did not refer due to confidence in their own skill. This tool can be used to correlate these constructs against other solid outcome measures to assist in service improvement and identifying research needs. It can also be used to determine clinicians’ educational requirements.
Patient-reported benefits of massage therapy as treatment for chemotherapy-related pain.
Authors: Menendez Alvaro G. , Carvajal Alejandro Ramon , Cobb Regina , Sahai Tanmay , D'Ambra Diane , Healey Kathi , Soriano-Pisaturo Maria
Published: February 2017

192

Background: Massage Therapy (MT) has been suggested to provide symptom relief of chemotherapy related side effects. Its impact on pain improvement, prevention, and overall quality of life (QoL) is characterized in this study and 2 different pain scales are being compared. Methods: Patients who were on active chemotherapy and agreed to receive at least one MT session over a 10-week period were included. Wong-Baker Pain scale (WBPS) and Numerical Pain Scale (NPS) were assessed pre and post every session. Results: 62 pts were included. 25 pts were on analgesics (Opiates 64%, Gabapentin 24%, NSAIDs 12%). 34/62 pts had no complaints of pain on enrollment and only 9% (3/34) developed pain as per WBPS on subsequent visits. In 27/28 pts (97%) who had pain initially according to WBPS (0-4 scale), improvement was reported from X = 1.25 (5±5, M = 0, SD 2.31) to X = 0.32 after one MT session (4±4, M = 0, SD 1.16) (p < 0.05). 25/28 pts (89%) had maintained improvement from 1st to 2nd session with an average of 50%. 11% (3/28) reported worsening of pain symptoms with an X increase average of 2.66 (3±1, M = 2). NPS was positive for 37 patients on initial visit. NPS revealed a similar trend with pre-massage X of pain from 2.76 (5±5, M = 2, SD 2.87) to 1.18 (4±4, M = 0, SD 2.01) after 1st session (39.5% improvement) (p < 0.05). 18/25 (72%) saw a decrease in pain level per NPS (X = 2.27) between each session, whereas 28% noted worsening of pain by the end of their participation. Conclusions: MT is a high-value, low-risk intervention for reducing cancer pain and cancer treatment-related pain. MT could be used to address patients' need for emotional and physical human connection at a time when their quality of life is fragile. MT may offer pain prophylaxis when provided in a cumulative manner. NPS appears to be more sensitive than WBPS for pain screening in oncologic patients. Further studies are necessary to confirm the suggested findings of massage therapy for pain prevention and treatment.
The combination therapy with methylphenidate and American ginseng in cancer-related fatigue.
Authors: Chang Young , Smith Joshua , Portman Diane G. , Oberoi-Jassal Ritika , Rajasekhara Sahana , Davis Mellar P.
Published: February 2017

215

Background: Fatigue is one of common symptoms among patients with cancer. However, little is known about the pathophysiology and effective pharmacologic intervention. Methylphenidate and American Ginseng were recognized for promising results and safe to use as a single therapy. Psycho-stimulants are commonly used and are effective in moderate to severe fatigue. The mechanism behind the evidence for methylphenidate is rebalancing dopamine neurotransmission which is altered in fatigue. The mechanism behind ginseng benefits appears to be improvement in muscle metabolism and reduction in inflammatory responses thought to cause fatigue in cancer. We hypothesized that combination therapy with methylphenidate and American ginseng is superior to single therapy and safe. Methods: We conducted retrospective chart review in the supportive care medicine outpatient clinic between Feb 01, 2015 and Dec 31, 2015. 28 patients were prescribed methylphenidate and American ginseng for 4 weeks. Methylphenidate dosage was between 10-20mg/day. American ginseng dosage was fixed at 2000mg/day (no control of sources). We investigated compliance rate, positive rate and change of fatigue score on ESAS. We also obtained the data for adverse effect ratio and severity as a safety measure. Results: We identified 28 patients (M: F 14/14, Age 50.4) who were prescribed combination therapy with methylphenidate and American ginseng for at least 4 weeks. 18 patients were compliant to combination therapy (Compliance rate 64%). 2 patients (11%) reported Grade 2 adverse effect while on therapy. One patient (5%) became non-compliant during the study period. 15 patients (84%) successfully completed the therapy the average fatigue score of pre and post intervention was 6.93 and 4.13 respectively (mean reduction -2.80, p-Value < 0.0002). 12 patients (80%) showed significant improvement of fatigue (reduced ≥ 2). There was no association between gender and age. Conclusions: Combination therapy with standard dose of methylphenidate and American ginseng were a safe and effective way of treatment for cancer-related fatigue. Further studies to confirm its safety and efficacy are justified.
Patterns of symptom control and palliative care-focused original research articles in major radiation oncology journals.
Authors: Di Giovanni Julia , Balboni Tracy A. , Chow Edward
Published: February 2017

216

Background: National oncology and palliative care organizations recommend greater incorporation of palliative care in clinical care and research in advanced cancer to improve care quality. In radiation oncology, palliative oncology care represents approximately 30-40% of treatment courses. Given the frequency of palliative care in radiation oncology and recommendations for greater research at this intersection, we sought to determine the prevalence and patterns of publication of symptom control and palliative care focused original research articles in two prominent radiation oncology journals from 2004-2015. Methods: From 2005 to 2014, abstracts of original research manuscripts published in the International Journal of Radiation Oncology (Red Journal) and the Radiotherapy and Oncology (Green Journal) journals were reviewed to determine the number and content of abstracts relating to symptom control and palliative care (SCPC). Research articles were included if their abstract described a patient population with advanced or metastatic cancer and were considered focused on SCPC if symptom palliation was the goal of treatment or patterns of palliative care needs was the goal of the research inquiry. Change in annual proportion of SCPC abstracts over time was assessed with the χ-square trend test. Results: From 2005 -2014, 10.6% (593/5611: range 4.2-17%) of all original research articles published in the Red Journal and 14.5% (365/2516: range 12.2-17.4%) published in the Green Journal involved palliative care. In the Red Journal, 1.3% (75/5611) of original research articles were specifically focused on SCPC and 5.3% (133/2516) in the Green Journal. In both journals the number of abstracts did not change over time (p = 0.24). Randomized controlled trials accounted for a minority (10.6%, 22/208) of SCPC abstracts in both journals. Conclusions: SCPC-focused original research is poorly represented in two major radiation oncology academic journals. Palliative radiotherapy is a critical part of radiotherapy clinical practice and should be the subject of further research; particularly needed is research employing rigorous study designs.
Insurer pre-authorization and copayment for palliative patients with cancer receiving opioids other than morphine.
Authors: Vidal Marieberta , Reddy Akhila Sunkepally , Rodriguez Eden Mae , Bruera Eduardo
Published: February 2017

217

Background: Uncontrolled pain is one of the main fears for patients with cancer and their families. Opioid analgesics are highly effective agents, but the choice of type, route, and dose needs to be personalized. The highly cost of some of them can make it difficult for patients to received adequate pain control without appropriate insurance coverage. There is a lack of information regarding the frequency of denials or heavy copayments by insurers. Methods: We evaluated 143 continuous opioid test claims for prescriptions by our palliative care providers for opioids other than morphine, including transdermal fentanyl, extended release oxycodone, hydromorphone and oxymorphone. We will categorize the test claims in 4 different groups: Approved with $0 to $49 dollars co-pay, Approved with high co-pay ($50 or more), Preauthorization required, and Direct Denial. Results: Among the 143 collected test claims 102 were for hydromorphone ER, 27 Oxycodone ER, Fentanyl TD 6 and Oxymorphone ER 8: 4 (3%) were rejected, 65 (46%) had a $0-50 copay , 28 (20%) had $50 or more copay and 46 (31%) needed prior authorization.). Conclusions: Only 65 ( 46%) of the prescriptions for opioids other than morphine had a copayment of 0-50$. Insurers’ copayment and requirements pose a major barrier for patients and physicians.
Improving provider adherence to evidence-based supportive care practices for patients with myeloma.
Authors: Stricker Carrie Tompkins , Faiman Beth , Harris Diana , Rozario Nicole
Published: February 2017

218

Background: Rapidly emerging therapeutics for multiple myeloma (MM) have diverse and sometimes life-threatening toxicities, underscoring the need for proactive screening, assessment, and management to mitigate symptoms and adverse events [AEs] (i.e., “supportive care (SC) practices”). Little is known about the real-world systematic use of such strategies in routine MM clinical care. A 3 center pilot study aims to describe documented adherence to evidence-based SC practices, and then intervene with a novel ePRO and supportive care planning system (CPS) technology designed to improve adherence. Methods: 90 patients and 90 controls with MM from 3 sites are being evaluated in this pilot study. A scorecard to measure provider use of evidence-based SC practices, at the patient level, was developed by an interdisciplinary team, using an iterative process of literature review and a modified Delphi technique to gain metric consensus. The scorecard is applied to medical records of intervention subjects and controls over an 8-12 week period. Results: Scorecards have been completed to date for 20 historical controls & 7 intervention subjects; remaining to be complete by meeting. For controls, screening for specific symptoms was fairly consistent, but documentation of detailed assessments (e.g., severity, functional impact) and management strategies was poor. For intervention subjects to date, screening almost always was documented, and both detailed assessment and intervention was better than for controls in most cases. See table. Conclusions: For controls, providers regularly documented symptom/AE screening, yet detailed assessments and evidence of interventions were inconsistently documented. Barriers may include the limited availability of effective interventions for symptoms such as CIPN & fatigue, as well as time barriers to effective symptom assessment and management, and its documentation. Almost all metrics were better in intervention subjects to date. Although documentation may not reflect actual practice, improvement in detailed assessment and management strategies is likely needed, and a novel CPS technology may improve this state of affairs; evaluation ongoing. [Table: see text]
Rolapitant for control of chemotherapy-induced nausea and vomiting (CINV) in patients with gynecologic cancer.
Authors: Rapoport Bernardo Leon , Schwartzberg Lee Steven , Arora Sujata , Powers Daniel , Jordan Karin , Navari Rudolph M.
Published: February 2017

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Background: Rolapitant, a long-acting neurokinin-1 receptor antagonist, protected against CINV in patients receiving highly or moderately emetogenic chemotherapy (HEC or MEC). Methods: In 3 double-blind phase 3 studies, patients were randomized to receive oral rolapitant 180 mg or placebo before administration of HEC or MEC. All patients received a 5-hydroxytryptamine type 3 receptor antagonist and dexamethasone. In a post hoc analysis of 3 pooled studies (2 HEC and 1 MEC), we assessed the efficacy and safety of rolapitant in patients with gynecologic (ovarian, uterine, or cervical) cancer. Endpoints included complete response (CR; no emesis and no use of rescue medication), no emesis, no nausea (maximum visual analogue scale [VAS] < 5 mm), and complete protection (CP; no emesis, no use of rescue medication, and no significant nausea [maximum VAS < 25 mm]) in the overall (0–120 h), acute (≤ 24 h), and delayed (> 24–120 h) phases. Results: Of 201 patients with gynecologic cancer (60% ovarian, 28% uterine, and 12% cervical cancer), 55% received cisplatin-based HEC and 44% received MEC (99% of whom received carboplatin-based therapy). In the overall and delayed phases, improved rates of CR, no emesis, no nausea, and CP were observed with rolapitant compared with control (Table). The overall incidence of treatment-emergent adverse events was similar in the rolapitant and control groups (45% vs 54%). Conclusions: Rolapitant protected against overall and delayed CINV in patients with gynecologic cancer receiving HEC or MEC. Clinical trial information: NCT01500226, NCT01499849, NCT01500213. [Table: see text]
Evaluation of the palliative benefit and toxicity of Ra-223 treatment of men with hormone refractory prostate cancer in a community setting.
Authors: Vaghefi Houman , Xiong Bide , Liu Fang , Garber Elizabeth , Wheeler James
Published: February 2017

225

Background: The ALSYMCA (Alpharadin in Symptomatic Prostate Cancer) trial was a phase III, placebo controlled, randomized trial in which 921 men with bone metastasis from hormone refractory prostate cancer (HRPC) were randomly assigned to receive radium-223 (Ra-223) or placebo. Ra-223 produced a 30% survival benefit, with a median survival of 14.9 months compared to 11.3 months for patients treated with a placebo, which led to FDA approval in 2013. Methods: We identified through the nuclear medicine records 11 patients who started Ra-223 between March 15, 2013 and December 10, 2015. The Wilcoxon signed rank test was used to compare the published results of the ALSYMPCA patients with those from our institution. Results: The Hodges-Lehman estimate of the median survival of our patients from the date of the first Ra-223 infusion was 7.8 months. The 95% confidence interval (CI) was (2.8, 14.7; p = 0.0122) indicating our patients had a significantly shorter survival. Our patients did not have a statistically significant worse rate of anemia, neutropenia, or thrombocytopenia. Only 27.3% (95% CI: 6.0, 61.0%) of our patients completed all 6 planned infusions significantly less than 63% for the ALSYMPCA patients treated with Ra-223 (p = 0.0239), but not statistically different than the placebo patients (p = 0.236). The median survival from the last Ra-223 was 3.53 months. We used 3 measures of treatment effectiveness: (1) reduction in the pain scores, (2) reduction in the serum PSA, and (3) reduction in the alkaline phosphatase. Compared to the pre-treatment values, numerical reductions were seen at the last follow-up evaluation for both the pain scores and the alkaline phosphatase levels, but the reductions were not statistically significant. Conclusions: Not all patients with castration resistant prostate cancer benefit from Ra-223 to the same extent as the ALSYMPCA patients. It is important to identify patients with a sufficient life expectancy to benefit from this treatment.