bluuebunny/crossref_metadata_2025 huggingface dataset:
Charlson score to predict overall survival and cancer-related death in elderly patients featuring high-risk prostate cancer.
Authors: Ordaz Guzman , Sanchez-Salas Rafael , Sivaraman Arjun , Joniau Steven , Bianchi Marco Giorgio , Briganti Alberto , Spahn Martin , Bastian Patrick , Chun Jongi , Chlosta Piotr , Gontero Paolo , Graefen Marcus , Karnes R. Jeffrey , Marchioro Giansilvio , Tombal Bertrand F. , Tosco Lorenzo , Van Der Poel Henk , Cathelineau Xavier ,   European Multicenter Prostate Cancer Clinical and Translational research group (EMPaCT), Lier, Belgium
Published: February 2017

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Background: In elderly patients, Charlson score among other features, might allow clinicians to limit the use of aggressive adjuvant treatment strategies or even primary surgical treatment to those who might not achieve benefit during their lifetime. Methods: Retrospective analysis, 7,650 case multicenter high-risk prostate cancer (Pca) radical prostatectomy database selecting >= 70 years old cases. We predicted death from all causes (DAC) and cancer related death (CRD) including all clinical and pathological data. Multivariable analysis were performed to identify independent predictors of DAC and CRD with binary logistic regression, using STATA® software, version 13.1. Results: 2,106 patients from 14 high-volume centers were included. Mean age was 72.8 years (SD 2.46). 206 (9.78%) patients were classified as ASA 3-4 and 497 (23.6%) as CS >=1. Mean PSA was 21.7 ng/ml (SD 50.5). At final histopathology, 800 (38%) had pT3b-T4 disease, GS was 8-10 in 589 (28%), LNI was found in 518 (24.6%) and 822 (39%) PSM. Adjuvant RT, ADT and RT+ADT were administered in 359 (17%), 391 (18.6%) and 437 (20.7%), respectively. Mean follow up was 5.18 years (DS 4.47). BCR occur in 649 (30.8%) and CF in 150 (7.1%) of which distant in 59 (2.8%). Total deaths accounted 341 (16.2%) and CRD for 100 (4.7%) cases. Conclusions: Multicenter data confirms that elderly patients survival harboring high risk prostate cancer will benefit from radical treatment if they are Charlson score 1 or less. [Table: see text] [Table: see text]
Accuracy of manual and automated rectal contours using helical tomotherapy image guidance scans during prostate radiotherapy.
Authors: Scaife Jessica Elizabeth , Harrison Karl , Drew Amelia , Cai Xiaohao , Lee Juheon , Schonlieb Carola-Bibiane , Sutcliffe Michael , Parker M Andy , Freeman Sue , Romanchikova Marina , Thomas Simon , Jena Raj , Bates Amy , Burnet Neil
Published: February 2017

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Background: Prostate radiotherapy can be delivered using daily image-guided helical tomotherapy. Previous work has shown that contouring the rectum on the kV planning CT scan has a Jaccard conformity index (JCI) of 0.78 for different oncologists (inter-observer variability) and 0.82 for a single oncologist (intra-observer variability) (Lutgendorf-Caucig C et al. Feasibility of CBCT-based target and normal structure delineation in prostate cancer radiotherapy: multi-observer and image multi-modality study. Radiother Oncol. 2011;98(2):154-61.). Using the daily image guidance MV CT scan we have developed automated methods to contour the rectum in order to investigate the dose delivered over a course of treatment. We sought to quantify the accuracy of MV manual and automated contours. Methods: A single oncologist (JES) contoured the rectum on 370 MV scans for 10 participants treated with helical tomotherapy to prostate and pelvic lymph nodes. Accuracy of MV manual contours was tested using a scalar algorithm to enlarge and reduce the contours and intra-observer re-contouring at a 3-month interval. Automated contouring, incorporating the Chan-Vese algorithm, was developed and outputs were compared with manual contours. Results: JES could identify differences in MV manual contour size at the level of ±2.2 mm, equivalent to 1.7 pixels. The median JCI for MV re-contouring was 0.87 with inter-quartile range (IQR) 0.78 to 0.90. When compared with manual contours, automated outputs had a median JCI of 0.79 (IQR 0.74 to 0.79). These results were obtained after 3 iterations, each taking less than 10 seconds. Conclusions: Manual contouring using MV scans was accurate, at a level of approximately 2 mm, and reproducible, with JCI of 0.87. The time taken to contour was approximately 20 minutes per scan. Automated contouring was also reproducible with JCI of 0.79 and, in contrast, took less than a minute per scan. Both manual and automated methods produced results comparable to those for contouring using kV scans. We plan to use auto-contouring to calculate accumulated dose to the rectum in an initial cohort of 100 participants. These doses will be correlated with toxicity as part of the VoxTox Study.
Can pelvic lymph node dissection be omitted in intermediate-risk prostate cancer patients? A SEER-based comparative study using inverse-probability-of-treatment weighting.
Authors: Chen Yu-Wei , Mahal Brandon Arvin Virgil , Ziehr David R. , Nezolosky Michelle Daniel , Viswanathan Vidya Bhavani , Choueiri Toni K. , Trinh Quoc-Dien , Nguyen Paul Linh
Published: February 2017

95

Background: To investigate whether pelvic lymph node dissection (PLND) reduces prostate cancer specific mortality (PCSM) in surgically-treated men with intermediate-risk prostate cancer (Pca). Methods: We identified 44,112 men diagnosed with intermediate-risk Pca from 2004-2009 in Surveillance, Epidemiology and End Results Program (SEER). We used inverse-probability-of-treatment weighting (IPTW) to adjust for baseline characteristics between PLND + radical prostatectomy (RP, N=26,571), versus RP alone (N=17,541) groups; Cox competing-risk model and propensity score-adjusted analyses were used for validation. Gleason scores were based on prostatectomy since biopsy scores were not available for RP-treated patients in SEER from 2004-2009. Results: After a median follow-up of 54 months, there was no survival benefit associated with PLND + RP compared to RP alone (Gray's test, P=0.30). After IPTW adjustment for baseline characteristics, PLND was still not associated with PCSM (AHR: 0.93, 95% CI: 0.65-1.33). This result was consistent with propensity score-adjusted model (AHR=1.05, 95% CI: 0.71-1.55) and the Cox competing-risk model (AHR=1.06, 95% CI: 0.71-1.57). Of men who received RP with PLND, 502 men (1.9%) had pathologically positive lymph nodes, which were associated with a higher risk for PCSM (AHR: 4.02, 95%CI: 1.83-8.84). Conclusions: PLND with RP was not associated with reduced PCSM compared with RP alone in men with intermediate-risk disease, suggesting that PLND is diagnostic but not therapeutic in this patient population. However, a caveat of this study is that risk group was defined by pathologic Gleason score; the 5% of clinically intermediate risk patients who are typically found to have Gleason 8-10 disease at prostatectomy could not be included in this analysis. [Table: see text]
The impact of HistoScannin in prostate cancer detection: A sextant-specific analysis of detection and on tumor volume.
Authors: Porres Daniel , Pfister David J. K. P. , Kuru Timur H. , Heidenreich Axel
Published: February 2017

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Background: In the search of optimized screening for prostate cancer (PCa), HistoScanning (HS) has been introduced to support detection and assessment of cancer foci. The aim of our study was the evaluation of the impact of HS in the diagnosis of prostate cancer by a comparison with the histopathological results after prostatectomy. Methods: 282 patients between 37 and 75 years with histologically confirmed, organ-confined PCa that were scheduled for radical prostatectomy underwent transrectal ultrasound prior to surgery. HS was evaluated compared to histology that was performed on removed prostates as to: 1) prediction of overall tumor volume and 2) accuracy of HS in detection of PCa lesions bigger than 0.2 or 0.5 ml, respectively, separated for each sextant. Results: HS tends to underestimate volume of cancerous lesions, particularly larger lesions > 8 ml. Using a 0.2 ml detection threshold, specificity and sensitivity of HS was between 29%-68% and 46-78%, depending on the sextant. For a 0.5 ml detection threshold, sextant-specific specificity increased to 59-92% and sensitivity decreased to 16-54%. Stratification according to pre-operational PSA-values did not improve performance characteristics of HS. Separate analysis of data from low grade tumor after d’Amico criteria showed that HS is not able to reliably detect these tumors. Conclusions: Overall, our study does not support a significant contribution of HS to PCa diagnostics.
Rehospitalization of advanced cancer patients in the year after diagnosis.
Authors: Whitney Robin L. , Bell Janice , Tancredi Daniel J , Romano Patrick S. , Bold Richard J. , Joseph Jill G.
Published: February 2017

10

Background: Among individuals with advanced cancer (AC), frequent hospitalization is often at odds with patient preference and is increasingly viewed as a hallmark of poor quality care. Hospitalization contributes substantially to costs and regional spending variation in this population, but patterns and reasons are poorly described in the literature. Methods: California Cancer Registry data linked with hospital claims were used to quantify hospitalization in the year after diagnosis among individuals with AC [colorectal, pancreatic, prostate, breast, non-small cell lung cancer (NSCLC)] between 2009-2012 (n = 25, 032). Multi-state models and multilevel log-linear Poisson regression were used to model re-hospitalizations as a function of individual and hospital characteristics, accounting for the competing risk of mortality. Results: Among individuals with AC, 71% were hospitalized, 16% had at least 3 hospitalizations, and 64% of hospitalizations originated in the emergency department. Re-hospitalization rates were significantly higher for black, non-Hispanic (IRR 1.3; 95% CI: 1.1-1.4); Hispanic (IRR 1.1; 95% CI: 1.0-1.2); or Asian/Pacific Islander (IRR 1.1; 95% CI: 1.0-1.2) race/ethnicity vs. white, non-Hispanic; for public (IRR 1.4; 95% CI: 1.3-1.5) or no insurance (IRR 1.2; 95% CI: 1.0-1.5) vs. private; for lower SES quintiles (IRRs 1.1-1.3) vs. the highest; for 1 and 2 or more (IRR 1.1-1.6) comorbidities versus none, and for pancreatic cancer (IRR 2.1; 95% CI 1.9-2.2) and NSCLC (IRR 1.7; 95% CI 1.5-1.9) vs. colorectal cancer. Re-hospitalization rates were significantly lower after discharge from a hospital reporting an outpatient palliative care program (IRR 0.90; 95% CI 0.84-0.96). Conclusions: Individuals with AC experience a heavy burden of hospitalizations, many of which originate in the ED. Discharge from a hospital reporting an outpatient palliative care program appears to protect against re-hospitalization. Efforts to reduce hospitalization and provide care congruent with patient preferences might focus on improving access to outpatient palliative care, particularly among subgroups at greater risk, including racial/ethnic minority groups, those with lower SES, comorbidities and pancreatic or NSCLC.
Attitudes of radiation oncologists toward palliative and supportive care in the United States: Report on National Membership Survey by the American Society for Radiation Oncology (ASTRO).
Authors: Wei Randy , Yu James B. , Mattes Malcolm , Thrasher Adrienne , Shu Hui-Kuo George , De Los Santos Jennifer F. , Paganetti Harald , Koontz Bridget F. , Abraham Christopher , Balboni Tracy A.
Published: February 2017

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Background: Radiation oncologists are frequently involved in providing palliative and supportive care (PSC) for patients with advanced cancers through delivery of palliative radiation. Whether they are confident in their ability to assess and initiate treatments for pain, non-pain, and psychosocial distress is unknown. The American Society for Radiation Oncology (ASTRO) surveyed its practicing members in the United States on self-assessment of their primary PSC skills, and access to continuing medical education on PSC. Methods: We electronically surveyed 4,093 practicing radiation oncologists in the United States. The survey consisted of 17-questions in five sections: demographics, PSC training, domains of PSC, perceived barriers as a radiation oncologist to initiate advanced care planning, and discussion on prognosis. Results: The majority (91%) of radiation oncologists surveyed believe PSC is an important competency for radiation oncologists. Most radiation oncologists reported that they are moderately confident in their ability to assess and manage pain and GI symptoms but less confident in their ability to manage anorexia, anxiety, and depression. Despite areas of decreased confidence, a large number (42%) of radiation oncologists do not receive any additional PSC education beyond their residency training. Lastly, a perceived fear of upsetting referring medical oncologists and lack of clinic time are concerns for radiation oncologists who may want to initiate goals of care/advance care planning discussions with patients and their families. Conclusions: Radiation oncologists are more confident in their ability to assess and manage pain than in their ability to manage depression, anxiety, anorexia, and fatigue. There is a need for increasing continuing medical educational efforts in PSC for practicing radiation oncologists, and strengthening PSC training in residency programs.
Referral practices of medical oncologists to palliative care for patients with metastatic non-small cell lung cancer (NSCLC).
Authors: Feld Emily , Horn Leora , Phillips Sharon E.
Published: February 2017

108

Background: Early implementation of palliative care has shown to improve quality of life and prolong survival in pts with metastatic NSCLC. We sought to investigate the attitudes and referral practices among medical oncologists treating pts with metastatic NSCLC. Methods: Participants were identified through the IASLC 2015 membership directory. All participants were contacted via email to complete an 18-question online survey that included demographic variables as well as questions on referral practice and attitudes regarding the role of palliative care in the treatment of metastatic NSCLC pts. Results: The response rate was 31% (93/303). The majority of participants (94%) practice in an academic setting and 57% had no prior palliative care training. 88% of oncologists report easy access to palliative care providers and 94% have an affiliated palliative care practice within their institution. 83% believe there is definitive evidence in the literature supporting the benefit of early palliative care; however, 40% feel this evidence supports only improved quality of life, not prolonged survival. 58% of oncologists agree that metastatic NSCLC pts should be referred to palliative care early in their disease course. In practice, however, they refer 19% of pts to palliative care at the time of first treatment initiation and this only increases to 38% when considering all referrals made when pts are actively receiving chemotherapy. Reasons for not referring pts include lack of symptoms (56%), belief that oncologists can manage palliative care needs independently (46%), not wanting to burden pts with appointments (41%), concern that referral may not be well received by pts (38%), and long wait times (20%). Reasons for referral include inadequately managed pain (97%), no further treatment options (70%), weak support network (71%), depression/anxiety (68%), other cancer-related symptoms (69%), dwindling treatment options (66%), and lack of time to address palliative care needs (58%). Conclusions: While most oncologists acknowledge the benefit of early palliative care consultation for metastatic NSCLC pts, a minority of pts are referred and strategies to improve referrals are needed.
Organizational factors influencing specialty palliative care utilization at academic cancer centers.
Authors: Schenker Yael , Rabow Michael W. , Crowley-Makota Megan , Waters Mallory Marie , Nkumsah Michelle , White Douglas B , Chu Edward , Smith Cardinale B. , Arnold Robert
Published: February 2017

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Background: Rates of early specialty palliative care utilization remain low, despite increasing familiarity and favorable attitudes amongst cancer center oncologists. In this context, understanding organizational barriers to specialty palliative care use becomes critical. Methods: We conducted a qualitative interview study with 74 medical oncologists practicing at 3 U.S. academic cancer centers with well-established specialty palliative care clinics. The in-depth interview guide elicited experiences and views related to outpatient palliative care. For this analysis, we focused on organizational factors influencing palliative care use, defined as the structural arrangements and social patterns that facilitate or impede implementation of best practices in healthcare. The team conducted mixed deductive and inductive coding, using Cabana’s quality improvement framework as a starting point. Key concepts were iteratively refined with interdisciplinary input. Two coders applied the final codebook to all transcripts, with disagreements reviewed and resolved by team consensus. Results: Participating oncologists were 68% male, specialized in solid tumors (61%), hematologic malignancies (32%), or both (7%), and had been practicing oncology for a mean of 17 (SD 12) years. Organizational factors impeding early specialty palliative care utilization included: the perceived burden on patients from spending more time at clinic appointments, which was balanced against the value added from specialty palliative care; social, financial, and disease-related factors interfering with patients’ ability to attend additional specialty visits; the clinic name, with concern that patients equated ‘palliative care’ with death, dying or giving up; an unwieldy referral process without availability of same-day appointments; and inadequate communication between oncologists and palliative care specialists. Conclusions: Even when oncologists are aware of the evidence and agree with recommended practices, organizational factors may impede adherence to oncologic and palliative care guidelines. Addressing these barriers could improve use of outpatient specialty palliative care.
Referral patterns to palliative care: An inpatient snapshot study.
Authors: Wong Aaron Kee Yee
Published: February 2017

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Background: Research suggests that palliative care referrals are not done as often or as early as required. In order to address potential barriers to referrals, current referral patterns need to be explored. We sought to identify the adequacy of palliative care referrals in hospital. Methods: We undertook a retrospective, cross-sectional study, censoring all inpatients on a single day from the largest tertiary hospital in the state. Each file was reviewed, and patients were identified as “palliative” based on the Gold Standards Framework criteria. Patients were followed for 3 months or until discharge, whichever was earlier. Results: Of the 873 inpatients, 134 patients were identified as palliative. Of the 95 patients who required formal palliative care input, only 28% were referred (27 patients). Specialty medical teams were the best at referring, whereas surgical teams were the worst. Only 50% of patients requiring terminal care and 10% requiring community palliative care (CPC) were referred. Conclusions: Alarmingly, most patients requiring palliative care were not referred (72% unreferred), most of these requiring CPC. Excluding CPC, still only 58% of patients requiring palliative care were referred. This is concerning, given data that shows that early integration of palliative care provides better quality of life, reduced depressive symptoms, and longer median survival. This suggests that either the severity of their illness is not recognised by treating teams, or that there is a lack of awareness in CPC, or possibly a lack of confidence in discussing it. There is a need for better referrals to palliative care, especially to CPC. Greater education is required, targeting the importance of early referrals. As used in this study, the Gold Standards Framework criteria can help identify patients who require referrals.
Variation in utilization of palliative surgery in patients with metastatic colorectal cancer.
Authors: Healy Mark Andrew , Nathan Hari , Regenbogen Scott E. , Hendren Samantha , Morris Arden M. , Suwanabol Pasithorn Amy
Published: February 2017

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Background: Twenty-five percent of patients with colorectal cancer will present with unresectable disease. Palliative surgery has been shown to improve symptom control and improve patient satisfaction as well as demonstrate improved cost and decreased healthcare utilization. However, it is unclear what factors influence use. We sought to determine patient and hospital factors associated with palliative surgery use in advanced colorectal cancers. Methods: Using the National Cancer Data Base (NCDB) Participant User File from 2006 to 2012, 162,967 patients with metastatic colorectal cancer were identified. Hierarchical regression was used to evaluate patient factors associated with use of palliative surgery. Hospitals were then categorized into quintiles based on palliative surgery utilization. Results: On multivariable analysis, factors associated with palliative surgery included rectal tumor site (OR 1.63, 95% CI 1.49 – 1.77), Asian/Pacific islander race, Medicaid/uninsured status, and longer duration from diagnosis to treatment (p < 0.05 for all). After stratifying hospitals into quintiles of utilization, significant regional variation in use of palliative surgery was noted. The lowest likelihood of use of palliative surgery was the NCDB South Atlantic region (DC, DE, FL, GA, MD, NC, SC, VA, WV). Compared to this region, hospitals with high use of palliative surgery were more common in the Pacific (OR 2.08, 95% CI 1.9-2.26), West South Central (OR 2.60, 95% CI 2.39 – 2.84), East North Central (OR 4.15, 95% CI 3.86 – 4.46), Mountain (OR 4.72, 95% CI 4.22 – 5.27), West North Central (OR 5.30, 95% CI 4.83 – 5.83), East South Central (OR 5.42, 95% CI 4.97 – 5.92), Middle Atlantic (OR 6.75, 95% CI 6.24 – 7.30), and New England (OR 6.75, 95% CI 6.05 – 7.54) regions. Compared to community cancer centers, high utilization hospitals were more likely to be academic/research centers or comprehensive cancer centers. Conclusions: In metastatic colorectal cancer, race and socioeconomic status appear to play a role in use of palliative surgery. It appears that use is higher for patients at academic/research hospitals or comprehensive cancer centers. Significant regional variation also exists in use of palliative surgery.
Identifying barriers to oncologist referral to palliative care: A dual approach.
Authors: Whelan Kyle
Published: February 2017

121

Background: Longitudinal palliative care has demonstrated benefits for cancer patients, and the American Society for Clinical Oncology recommends that palliative care be used along with standard anti-cancer therapy at the diagnosis of serious disease. However, studies have shown that oncologists still often refer to palliative care within days of the end of life, or not at all. This indicates that oncologists face barriers, systems-based or self-imposed, to palliative care referral. This study aims to identify specific barriers that prevent oncologists from referring cancer patients to palliative care services. Methods: Barriers to referral were identified via a dual approach. A literature review was performed using a PubMed search of articles published since 2012, when the ASCO provisional opinion was issued. This was narrowed down to 27 articles that meaningfully commented on barriers that oncologists face in referring to palliative care. Additionally, a qualitative analysis of semi-structured interviews of five practicing oncologists was performed. Oncologists interviewed for the study practice in a cancer center affiliated with an academic tertiary hospital. Results: 20 distinct barriers to referral, both systems-based and at the individual provider level, were enumerated from the literature review and interview analysis. Conclusions: Oncologists face a wide range of specific barriers that prevent appropriate referral to palliative care, related both to the logistics of the healthcare system and to providers’ preconceptions about palliative care. A significant barrier at the oncologist level is a tendency to associate palliative care exclusively with the end of life, despite demonstrated benefits earlier in the course of disease.
The extended care unit: A feasible economic solution for longer-term palliative inpatients.
Authors: Wong Aaron Kee Yee
Published: February 2017

143

Background: Many inpatient palliative care units (PCUs) in Australia require patients who cannot go home, but remain stable after 2 weeks, to be discharged to nursing homes (NHs). This involves moving between 5 locations (home, acute hospital, PCU, NH transition bed, NH), in the final weeks of life. We propose an “Extended Care Unit” (ECU) to avoid unnecessary moves for such patients. This study aimed to investigate the feasibility of the proposed ECU, including identifying demand, admission criteria, length of stay, and hospital costs. Methods: Using a retrospective, observational design, we censored all inpatients on a single day from the largest tertiary referral centre in the state. 475 files were reviewed. ECU admission criteria used were: prognosis < 90 days, unable to return home, and NH referral process commenced. Two predictive mortality scores were calculated. Total cost was calculated based on average bed cost over 12 months. ECU bed costs were based subacute aged care bed costings. Results: Fifteen (3%) patients met ECU admission criteria. 80% (n = 12) died within 90 days. 60% were transferred between ≥ 4 places. After fulfilling ECU admission criteria, a further 279 acute and PCU bed days were used. If an ECU were available, hospitals would save $207.70 per patient per bed day. Conclusions: The ECU model is a feasible economic solution for this demographic of patients whose needs are currently poorly met. We provide evidence of clear demand, with significant cost savings. Effective admission criteria to identify suitable patients for the ECU are also proposed.
Piloting survivorship care planning with the metastatic breast cancer patient.
Authors: Bantug Elissa Thorner , Saiki Catherine , Zorzi Jane , Stearns Vered , Wolff Antonio C.
Published: February 2017

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Background: Emotional distress and poor symptom management are highly prevalent among patients with metastatic breast cancer (MBC). A high disease burden can further negatively impact these patients’ quality of life. To address the evolving survivorship needs in their trajectory from initial diagnosis of advanced disease to end-of-life care, patients with MBC require prompt assessment, reevaluation, and specialized support services. Limited survivorship resources are devoted to this patient population and greater attention to their needs is warranted. Methods: To address the survivorship needs of patients with MBC Johns Hopkins, we developed a new initiative designated a “Living with Breast Cancer” appointment. During this dedicated clinic encounter, a palliative care nurse practitioner works with the patient and her caregiver to develop an individualized “survivorship care plan” that describes medical and psychosocial care, symptom management, nutrition counseling, goal setting, mind/body techniques, palliative care, legacy work, pain management, health screening recommendations, family support, community referrals, and care coordination with oncology providers, among others. Patients with stable MBC are referred to this service by our medical oncology team. Patients are then asked to complete an evaluation survey (either by email or over the phone) 4-6 weeks after the appointment. Results: Since the initiation of program in March 2016, we evaluated 8 patients (3 African-Americans; 3 Caucasian; 2 Asians); mean age is 54.1 years (range, 38-75). Most patients were approximately 1-year post diagnosis of MBC (range, 1-10 years). We are currently collecting and analyzing evaluation survey results. At the time of the meeting, further demographics and evaluation results through August 2016 will be reported. Conclusions: If successful, the Living with Breast Cancer initiative may allow for more patient-centered care of individuals with MBC and their families at Johns Hopkins. The creation of an infrastructure for care coordination, survivorship support services and education aims to promote individualized services within the metastatic setting and improve the quality of life for this population.
The integration of palliative care into treatment of oncology patients at the Istituto Oncologico Veneto (IOV): The interdisciplinary clinic of simultaneous care.
Authors: Galiano Antonella , Schiavon Stefania , Brunello Antonella , Michielotto Michela , Guglieri Irene , Nardi Maria Teresa , Lamberti Evelina , Stablum Annalisa , Capovilla Eleonora , Trentin Leonardo , Zagonel Vittorina
Published: February 2017

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Background: WHO defines palliative care as an approach that improves the quality of life of patients (pts) and their families facing problems associated with life threatening illnesses. This occurs by means of early identification, assessment and treatment of pain and other problems physical, psychosocial, and spiritual. Recently, palliative care has been incorporated into the treatment of oncology pts earlier in the course of their disease. We aimed to explore this approach at our institution. Methods: We established an interdisciplinary clinic at IOV with the goal of promoting pts’ comprehensive support by integrating palliative care into active oncology treatments. Our primary objectives were to: optimize the quality of life of pts at every stage of their disease, ensure continuity of care through proper coordination of available services and avoid a sense of abandonment at the end of life. Pts included were those with advanced disease who had a life expectancy of less than one year, pts who had symptomatic disease regardless of prognosis, and pts who were considered frail, because of clinical, social, psychological, spiritual, logistical, and economical criteria. The multidisciplinary team consisted of a medical oncologist, a palliative care physician, a psychologist, a nurse and a nutritionist. Results: Between March 2014 and March 2016, 337 pts were visited, with different types of cancer. Median age was 69 (range: 34-93), 44% were men, median PS (ECOG) was 1.5, 47% were undergoing anti-cancer treatment. Reasons for referral included: physical complaints (71%), psychosocial issues (30.3%), nutritional problems (38%) and social problems (7%). For the 46% of patients, domiciliary health care was activated directly by the Local Health Department or through the General Practitioner; specific action have been made in relations to the problems encountered. Conclusions: The Interdisciplinary Clinic of Simultaneous Care carried out at IOV represents a successful pilot experience that proposes an organizational model for early integration of palliative care as an integral part of treating the oncology patient.
Embedding palliative care (pc) in a community-based cancer center: Benefits and barriers.
Authors: Bayne Jennifer , Weems John , Siegel Robert D. , Bowen Teresa N. , Stinnett Leigh , Ashley Jennifer
Published: February 2017

153

Background: The importance of involving PC early in the disease process of oncology patients is well documented. Decreased symptom burden, increased quality of life, and extended survival are proven outcomes; however, the provision of PC has largely been limited to the acute care setting in most institutions. Bon Secours St. Francis Health System, a community based healthcare system in Greenville, South Carolina, opened a comprehensive cancer center in late 2014. Our established inpatient PC team began seeing outpatients at the cancer center shortly after its opening. Methods: PC at the cancer center is provided in an “embedded” model of care. PC appointments were initiated at 20 hours/week and have been expanded to 28 hours/week, currently provided by NPs 24 hrs, MD 4 hrs, all of whom are certified in hospice and palliative care. Patients are seen during medical oncology, radiation oncology, or infusion appointments. In August 2015, the PC team began to participate in an interdisciplinary team meeting, reviewing new oncology patients and their expected or known needs. Results: Total visits for 2015: 559/158 new patients seen. Informal interviews from patients, oncology, and PC staff revealed the following benefits: better communication regarding treatment plans; improved symptom management; flexibility and convenience in meeting patients anywhere in the cancer center and; providing resources for staff regarding pain and symptom management and communication techniques. Barriers identified were: scheduling conflicts for patients with multiple appointments; less than full-time coverage by PC prohibits some patients from being seen during their oncology appointments; PC and oncology being separate administrative entities has required creative solutions in billing and staffing. Conclusions: Despite some barriers, the benefits of embedding a PC clinic in a community-based oncology center are clear and worthwhile. This clinic improves coordination of care between inpatient and outpatient services, which results in positive patient experiences. It is hoped that the early integration of PC in the ambulatory setting will result in a decrease in avoidable emergency room visits and hospital admissions.
Integrating a palliative care longitudinal track into a family medicine residency program.
Authors: Dalla Tor Nelson E.
Published: February 2017

156

Background: Palliative care and Palliative care skills are being instituted in many hospitals and clinics as they have been shown to improve health care outcomes and decrease costs. While health care organizations are adopting these coordinated care programs, finding competent physicians to work effectively in these programs is difficult. Methods: PIH Health Hospital Whittier Family Medicine Residency Program developed a longitdudinal Palliative Care and Chronic Disease track to generate a transformed workforce of future family physicians that can deliver innovative, empathetic and effective care for seriously ill patients who are at risk due to health disparities, advanced multiple chronic conditions, or frailty. We applied for and obtained a Unihealth grant to fund the track development as well as funding through our sponsoring hospital. The Palliative Care track has its own NRMP residency Match number, differentiating it from the categorical residency program. Each year we accept two residents to enter our track. Using a multidisciplinary approach and faculty, the track meets every two weeks in seminar sessions to train residents in the broad scope of Palliative Care. As part of the track, residents then rotate two months in their senior years in our hospital's palliative care service. Results: An exhaustive medical literature review has shown that our program is unique in its scope and breadth. We have accepted our fifth class of residents that will be entering the track this July, 2016. Conclusions: PIH Health Hospital Whittier Family Medicine Residency Program has created an unique and academically sound program to train Family Medicine residents in Palliative Care.
Integrating palliative care services in oncology clinics: An application of the Edmonton Symptom Assessment System (ESAS).
Authors: Rauenzahn Sherri L. , Schmidt Susanne , Jones Jessica , Aduba Ifeoma , Tenner Laura LaNiel
Published: February 2017

168

Background: Research inpalliative care has shown improvements in overall survival, quality of life, symptom management, care satisfaction and reductions in the cost of care. Therefore, the American Society of Clinical Oncology has recommended early concurrent palliative care in patients with advanced cancer and with high symptom burden. Despite this recommendation, integrating palliative services at our NCI-designated cancer center has been challenging. The aims of this project were to quantitatively describe the symptom burden of patients in ambulatory oncology clinics; facilitate the establishment of an effective referral system by detecting discrepancies between symptom burden and referral practices; and improve the integration of palliative care services by implementing the Edmonton Symptom Assessment System (ESAS) tool into 5 of our oncology clinics. Methods: ESAS forms consist of 10 questions assessing patient symptom burden and quality of life. Total scores range from 0 to 100. This tool was distributed to patients at two breast, two gastrointestinal and the thoracic clinics at each visit. The provider reviewed the forms and decided if a palliative care referral was appropriate based on patient responses. The forms as well as referral decisions were entered into REDCap. Over a 5 month period, 607 patients completed the initial assessment and 430 follow up forms were collected, resulting in a total of 1,037 scores collected. Results: The mean ESAS score for all patient visits was 20.7 (SD = 18.7). Only 3.5% (n = 21) of all patients were initially referred to palliative care and 2.6% (n = 11) of patients were referred on follow up visits. Those with an initial referral had an initial mean score of 39.0 (SD = 19.0) and a mean follow up score of 31.9 (SD = 19.5). Conclusions: This project highlights the low palliative care consultation rate and the under-utilization of services by most oncologists at the cancer center despite using the ESAS tool. However, those who received a referral had lower ESAS scores at follow-up. We propose utilizing a trigger that would capture a preset percentage of patients who indicated scores reflective of high symptom burden and distress.
Acute pain management in radiation oncology: Quality of care and the impact of an integrated palliative oncology service.
Authors: Garcia Michael A , Balboni Tracy A. , Braunstein Steve E. , Fogh Shannon E. , Anderson Wendy , Pantilat Steve , Taylor Allison , Spektor Alexander , Krishnan Monica Shalini , Haas-Kogan Daphne A. , Hertan Lauren Michelle
Published: February 2017

195

Background: Radiotherapy (RT) effectively palliates bone metastases, but relief may take weeks, frequently necessitating acute pain management (APM). NCCN Guidelines for Adult Cancer Pain (V2.2015) recommend initiation/titration of analgesics for patients with pain scale value (PSV) ≥ 4. We sought to evaluate how often symptomatic patients have analgesic regimens assessed and intervened upon at radiation oncology (RO) consult for bone metastases, and the impact of a dedicated palliative RO service on APM. Methods: We reviewed consult notes for 217 bone metastases patients treated with RT at Dana Farber Cancer Institute/Brigham & Women’s Hospital (DFCI/BWH) and University of California, San Francisco (UCSF) during June-July 2008, Jan-Feb 2010, Jan-Feb 2013, and June-July 2014, time periods before and after implementation in 2011 of a dedicated palliative RO service at DFCI/BWH. For symptomatic patients, rate of assessment of analgesic regimen was recorded. Among patients with PSV ≥ 4, rate of pain intervention was recorded. The impact of a palliative RO service on these rates was evaluated. Results: Median age was 63 and median KPS was 70. Median PSV for painful bone metastases was 5 (IQR 2-7); 51% had PSV ≥ 4. Among symptomatic patients, analgesic regimen was assessed for 44.5% (51.7% at DFCI/BWH and 28.1% at UCSF). Among patients with PSV ≥ 4, pain intervention occurred for 17.2% (20.5% for DFCI/BWH, 0% for UCSF). At DFCI/BWH, consultation by a dedicated palliative RO provider was associated with higher rate of assessment of analgesic regimen (82.4% vs 47.7%, p = 0.007). At DFCI/BWH, consultation by a palliative RO provider was associated with higher rate of pain intervention (31.2% vs 7.9%, p = 0.012). There was no difference in analgesic regimen assessment or intervention between non-dedicated palliative RO providers at DFCI/BWH and UCSF (p = 0.07 and 0.09, respectively). Conclusions: At two cancer centers, half of bone metastases patients seen for RT have PSV ≥ 4, yet a minority have analgesic assessment and intervention, indicating need for APM quality improvement in RO. An integrated palliative RO service was associated with improved assessment and management of acute pain per NCCN guidelines.
Effect of food on the pharmacokinetics of dronabinol oral solution versus dronabinol capsules in healthy volunteers.
Authors: Smith Christina Cognata , Oh D. Alexander , Parikh Neha , Khurana Varun , Vetticaden Santosh
Published: February 2017

199

Background: Dronabinol, a pharmaceutical tetrahydrocannabinol (THC), capsule is approved for anorexia associated with weight loss in patients with AIDS and for cancer chemotherapy-induced nausea/vomiting in patients with inadequate response to conventional antiemetic therapy. Food effects on absorption and bioavailability of a new dronabinol oral solution was compared with marketed capsules. Methods: In an open-label, single-dose, 3-period crossover study, healthy volunteers were randomized to receive dronabinol oral solution 4.25 mg (fed) or dronabinol capsule 5 mg (fed or fasted), after a 7-day washout period. Doses were administered under a fasted (overnight) or fed state (high-fat/calorie meal 30 minutes pre-dose). Plasma pharmacokinetics was evaluated for dronabinol and the major metabolite, 11-OH-Δ9-THC. Results: Pharmacokinetic data of 54 volunteers were analyzed. In the fed state, initial dronabinol absorption was rapid with oral solution versus capsules (mean Tlag, 0.15 vs 2.02 h), and 100% and 15% of volunteers receiving oral solution and capsules, respectively, had detectable plasma dronabinol levels 30 minutes post-dose. Inter-individual variability in plasma dronabinol concentrations during early absorption was less with oral dronabinol solution (%CV: 82.79%, 83.94%, and 90.68%) versus capsules (%CV: 318.54%, 250.33%, and 182.01%) observed at 0.5, 1, and 2 h, respectively, after dosing. Food increased mean AUC0-t similarly for dronabinol oral solution and capsules, versus capsules with fasting, increasing exposure to oral solution and capsules 2.1- to 2.4-fold. Mean Tmax was similarly delayed for dronabinol oral solution (7.7 h) and capsules (5.6 h) with food relative to fasting (1.7 h). On the basis of 11-OH-Δ9-THC plasma levels, AUC0-t up to 48 h postdose and AUC0-inf were found to be similar for the oral solution and capsules under fed conditions. Conclusions: An appreciable food effect was observed for dronabinol oral solution and capsules. Dronabinol oral solution may offer therapeutic benefit to patients given its rapid absorption and lower inter-individual variability compared with dronabinol capsules. Clinical trial information: NCT01448772.
Systematic review of interventions to facilitate advance care planning (ACP) in cancer patients.
Authors: Chan Bryan , Sim Hao-Wen , Zimmermann Camilla , Krzyzanowska Monika K.
Published: February 2017

21

Background: ACP refers to the process of consideration, documentation and communication of preferences for future care. ACP is crucial for patients (pts) with advanced cancer as it can guide substitute decision makers (SDM) and health care providers (HCP) to align care with preferences, thus improving quality of end-of-life care. Methods: We performed a systematic review of MEDLINE, EMBASE, CINAHL, PsycINFO and Cochrane (Systematic Review and Clinical Trial) databases (1995 to 2015) to identify interventions that facilitate ACP for cancer pts (documentation or discussion of advance directives, SDM or code status). We extracted data on study design, setting, subject numbers, interventions and outcomes. Study quality was assessed using a modified Downs and Black checklist. Results: Of the 64,196 unique citations identified, 10 studies met inclusion criteria for testing interventions using a pre-post or controlled trial design (median sample size 134, range 48-9105). Interventions were categorized based on target audience: health system (n = 4), pts and caregivers (n = 3) or HCP (n = 3). Types of interventions included: introduction of ACP facilitators (n = 4), reminders or prompts (n = 2), and HCP training, videos, website or pt screening (n = 1 each). Heterogeneity in study design, outcome measures and small sample sizes limited study quality and precluded meta-analysis. Prompts such as medical record or email reminders were most consistently associated with improved ACP documentation. System changes incorporating the use of ACP facilitators also improved ACP documentation in 3 out of 4 studies. Interactive HCP training significantly improved confidence to initiate ACP discussions which has been identified as a barrier to timely ACP. Pilot trials showed no significant increase in ACP with educational videos/websites directed at pts. Passive HCP education and one-off reminders were also ineffective. Conclusions: The complexity of ACP is reflected in the multitude of interventions that have been evaluated but none are ready for wide-scale adoption. Further studies of interventions such as prompts and ACP facilitators are needed to inform the best approach to improve ACP uptake in cancer pts.
Evaluation of combined argon plasma coagulation and savary bougienage for the relief of dysphagia of esophageal squamous cancer patients in the end of life.
Authors: Jia Ruinuo , Dong Caihong , Shan Tanyou , Yuan Xiaozhi , Li Shuoguo , Ding Xuezhen , Gao Shegan
Published: February 2017

214

Background: To relieve the dysphagia is a critical treatment for advanced esophageal cancer patients’ palliative care in their end-of-life. The ideal way is to satisfy both the patient’s nutrition supplement and self-taste. Although several endoscopic dilation techniques have been reported, the high incidence of dysphagia quickly relapsing remains. The aim of this study was to compare the effect of Argon Plasma Coagulation (APC) combined with Savary bougienage (SB) and SB alone for the relief of dysphagia of esophageal squamous cancer in the end-of-life. Methods: Patients with dysphagia for local advanced esophageal squamous cell carcinoma or local tumor recurrence and no any radiotherapy or surgery chance were randomly assigned to undergo APC combined with SB or SB alone. Primary endpoints were the dysphagia-free survival (DFS, be defined as the time from first dilation of effectively relieved dysphagia to dysphagia relapse, days) after 3 months followed up. Results: A total of 60 patients from Cancer Institute, First Affiliated Hospital of Henan University of Science and Technology were included in the study (SB group, n = 30, Combination group [APC combined with SB], n = 30), 2011. October 1-31, 2015. Primary endpoints: 3 months after treatment, DFS of Combination group (30.63 days; 95% CI, 20.31-36.95) was significantly longer than the SB alone group (5.3 days; 95% CI, 3.01-8.84, P = 0.000). No severe complications occurred within both of two groups. Conclusions: APC combined with SB was a safe and well-tolerated method for relieving dysphagia of advanced esophageal squamous cell cancer patients in the end-of-life, more investigation should pay on if this dilation method could obviously improve the life quality of patients and family by questionnaire as well. Clinical trial information: ChiCTR-TRC-13003757.