bluuebunny/crossref_metadata_2025 huggingface dataset:
Real-world evidence in the treatment of metastatic non-small cell lung cancer in a single institution of Colombia in the period August 2015 to August 2018.
Authors: Pino Luis Eduardo , Ospina Serrano Aylen Vanessa , Triana Ivan Camilo
Published: May 2019

e18204

Background: In Colombia, lung cancer is the first cause of mortality. However, there is a large gap in terms of the information available regarding the characteristics and survival of these patients in the country. Methods: This is an observational, descriptive study of a cohort of patients with stage IV non-small cell lung carcinoma who initiated medical treatment at Fundación Santa Fe de Bogotá, a high complexity hospital. We analyzed clinical characteristics, oncogenic addiction expression, PDL1 expression, treatments, progression free survival (PFS), overall survival (OSm) and treatment related complications. Results: Twenty-six patients were included during the 3 years. The OSm for all the cohort was 19.6 months(m). In the group without PDL-1 expression and negative for oncogenic addiction that received treatment with chemotherapy the OSm was 16.9m and the PFS 9.6m. The OSm for the group with EGFR mutation that received target therapy was 24,7m and the PFS 13.11m. The patients with ALK rearrangement treated with target therapy had an OSm 17m and PFS 5m. The group with expression greater than 50% for PDL-1 that received only immunotherapy OSm was 9.5m and PFS 9m, and in the group with expression for PDL-1 between 1-49% the median OSm and PFS has not been reached. In relation with grade 3 toxicity, 7% of patients that received chemotherapy had kidney failure, 7% emesis and 15% hyporexia. Patients that received target therapy 9% had diarrhea and 9% hepatotoxicity. 9% of patients with bevacizumab presented bleeding and 8% of patients with immunotherapy had autoimmune colitis, in all these cases the medication was suspended. Hypothyroidism was the most frequent complication with the immunotherapy, and it was resolved with substitution therapy. Conclusions: Clinical characteristics and outcomes of this cohort were similar to other lung cancer patients series. Factors like cigarette, nutritional status and ECOG were no significant in the survival. 34,6% of patients had EGFR mutation and 7% had ALK rearrangements. Related to PDL1 we found 26% expresser patients. The highest OS and PFS was for the group with the EGFR mutation and for the group with PDL-1 expression between 1-49%.
A systematic review of surrogate endpoints (SEPs) for overall survival (OS) in metastatic colorectal cancer (mCRC).
Authors: Anand Seerat , Tannenbaum Daniel , Horn Robert Asa , Morris Van K. , Johnson Benny , Eng Cathy , Kopetz Scott , Overman Michael J. , Raghav Kanwal Pratap Singh , Dasari Arvind
Published: May 2019

e18206

Background: Although progression free survival (PFS) and overall response rate (ORR) are common endpoints in mCRC trials, validation of these as SEPs for OS across the evolving landscape of systemic treatment in mCRC, with novel therapeutics and expanding lines of treatment, is limited. We aimed to evaluate the potential surrogacy of PFS and RR for OS and explore variations across trial factors. Methods: We identified phase 3 randomized trials of systemic therapy in mCRC between 1986 - 2016 from 4 electronic databases. Data regarding endpoints and trial variables were extracted from published reports. Spearman’s coefficient (r) and linear regression were used to evaluate rank correlations between A) PFS and ORR with OS of both treatment and control arms (arm level analysis); B) net improvement in outcomes using hazard ratio (HR) for PFS and relative risk (RR) for ORR with HR for OS (trial level analysis). Results: A total of 128 trials containing 233 and 230 arms reporting on PFS and ORR, respectively, were identified. Arm level analysis revealed that correlation of PFS and ORR with OS was 0.69 (95%CI: 0.6 – 0.7) and 0.79 (95%CI: 0.7 – 0.8), respectively ( P < 0.001). Of 86 trials with reported HR for OS, PFS and ORR ratios were obtained for 84 and 74 trials, respectively. Trial level analysis revealed that correlation of PFS and ORR treatment effect with OS was 0.71 (95%CI: 0.6 – 0.8) and 0.58 (95%CI: 0.4 – 0.7), respectively ( P < 0.001). Level of correlation for PFS and ORR varied with line of therapy, type of therapy and trial size (Spearman r shown in table). Conclusions: Both ORR and PFS are appropriate SEPs for OS for systemic therapy in mCRC but their relative value varies notably with line/type of therapy and study size. Judicious use of these SEPs in clinical trials accordingly to supplant OS may help improve trial designs and performance.[Table: see text]
Patient reported outcomes in cancer patients: Psychological, physical and functional importance.
Authors: Shrotriya Shiva , Estfan Bassam N. , Sharma Mukta , Rayamajhi Supratik , Walsh Declan
Published: May 2019

e18209

Background: Patient-reported outcomes (PROs) allow consistent monitoring of patients’ symptoms and quality of life. We evaluated their prevalence among cancer patients. We also evaluated the association of PROs, Emotional Thermometer (ET) distress with demographic and disease characteristics. Methods: PROs were prospectively collected as cross sectional data. This was later combined with retrospectively obtained clinical data from the EMR. Predictors of ET component (Distress, Anxiety, Anger, Depression) was determined by linear regression analysis. The predictors of those who required Help with tablet computers was determined by logistic regression. Results: The mean age was 58 (±14) years; 54% male. The common cancer diagnoses were breast 17%, hematological (leukemia) 17% and lymphoma 12%. Few (7%) participants required help (N = 1076) with the tablet-based surveys. Age ≤ 30 and 51–70 years scored lower in mean depression ET. African Americans had higher ET Anger scale. African Americans scored higher in need of Help –ET. Age 31-50 years was at 13% lower risk and 51–70 years was at 72% lower risk of requiring help. Those with self-care problems were at higher risk of requiring Help with tablet computer. Conclusions: Many cancer patients visiting the cancer center had high pain/discomfort, anxiety/depression, problems with usual activities and mobility problems. Younger patients (31-50 years) had more distress and depression (ET). African Americans reported more problems with mobility, self-care, usual activities, pain/discomfort and anxiety/depression (EQ5D). Those with self-care problems were at risk to require help with tablet-based surveys.
Opportunity for performance measurement: 30-day mortality following cancer surgeries across U.S. hospitals.
Authors: Lipitz-Snyderman Allison , Lavery Jessica A. , Bach Peter , Li Diane G. , Yang Annie , Strong Vivian E. , Russo Ashley , Panageas Katherine
Published: May 2019

e18221

Background: While public reporting of surgical outcomes for non-cancer conditions is common, measures of outcomes following surgery for cancer have generally been excluded. This is true even though numerous studies show large variations between hospitals. We assessed whether prerequisites for quality reporting are present for the measure of 30-day cancer surgical mortality: low burden for timely reporting, hospital variation, and potential for public health gains. Methods: We used Fee-for-Service (FFS) Medicare claims to examine the extent of variation in 30-day mortality between 3,860 U.S. hospitals performing cancer surgery for patients ≥66 years, 2011-2013. Hierarchical mixed-effects logistic regression models adjusted for patient and hospital characteristics and with a random hospital effect were fit to obtain hospital-specific risk-standardized mortality rates (RSMRs) and 99% confidence intervals (CI). From these models we calculated a hospital odds ratio to describe the difference in the mortality risk for a hospital above versus below average quality and estimated the potential reduction in mortality under a scenario of improved quality for the lowest performers. Outcomes included extent of hospital variability in 30-day mortality after cancer surgery; and impact on lives saved from improving performance at outlier hospitals. Results: Over the three-year observation period, the median number of cancer surgeries performed per hospital was 34. For individual cancer sites, it was < 10, except for breast (median 17) and colorectal (median 14). The median RSMR overall was 2.41% (99% CI 2.28%, 2.66%). Breast had the lowest RSMR (median 0.24%) and gastroesophageal the highest (median 5.72%). In aggregate and for most individual cancers, variation between hospitals exceeded that due to differences in patient and hospital characteristics, and was robust to excluding emergent cases. For individual cancer sites, relative differences exceeded 20% in the risk of 30-day mortality between patients undergoing surgery at a hospital below average quality versus above average quality, with the potential for an estimated 500 deaths prevented annually given hypothetical improvements. Conclusions: Quality measurement and reporting of 30-day mortality for cancer surgery is worthy of consideration.
The prognostic value of patient-reported outcomes (PROs) for survival outcomes in cancer patients: A systematic review.
Authors: Cottone Francesco , Collins Gary S. , Giesinger Johannes M. , Sommer Kathrin , Deliu Nina , Vignetti Marco , Anota Amelie , Efficace Fabio
Published: May 2019

e18223

Background: Several studies have indicated that PROs may independently predict survival outcomes across various cancer populations. We aimed to synthesize current evidence in this research area and to investigate methodological quality of these studies. Methods: We conducted a systematic review of published studies (from January 2016 to December 2017) in oncology, which included at least one PRO domain in a multivariable prognostic model for survival outcomes. We used absolute and relative frequencies to assess the main characteristics of the studies, including tumor site, type of PRO questionnaire, type of PROs assessed (e.g., symptoms or functional scales) and their statistical significance for survival outcomes. As such studies pose important statistical challenges, we also investigated methodological issues based on a comprehensive set of predefined criteria. Results: Out of 385 candidate articles, 65 studies met eligibility criteria. Out of these, n = 56 (86%) reported at least one PRO as a statistically significant prognostic factor in a multivariable prognostic model and thirty-two studies (49%) were done with patients with metastatic/advanced cancer. Overall, the most used instrument to assess PROs was the EORTC QLQ-C30 questionnaire (n = 29, 45%) and the most frequent tumors were lung (n = 18, 28%), esophagogastric (EG) and gynaecological (GY) cancer (each n = 11, 17%). Among these, statistically significant prognostic PRO scales from the EORTC-QLQC30 included fatigue, pain and appetite loss for lung; nausea/vomiting, pain, dyspnea, appetite loss and constipation for EG and physical and role functioning for GY. With respect to methodological quality, we found important drawbacks. For example, only 24% assessed multicollinearity among PRO scales and only 29% assessed performance of the prognostic multivariable model (e.g., evaluating discrimination and calibration). Conclusions: In recent years, a remarkable number of studies has found that PROs provide prognostic information beyond well-established clinical and socio-demographic factors. However, some key methodological limitations have been found, which deserve special attention in future studies.
Perioperative therapy in patients with metastatic colorectal cancer.
Authors: Alese Olatunji B. , Zakka Katerina Mary , Huo Xingyue , Jiang Renjian , Shaib Walid Labib , Wu Christina , Akce Mehmet , Sullivan Patrick S. , Behera Madhusmita , El-Rayes Bassel F.
Published: May 2019

e18231

Background: Knowledge about perioperative systemic therapy in metastatic colorectal cancer (mCRC) is limited. We aim to describe the nationwide pattern of use and survival outcomes of patients with mCRC treated with surgical resection. Methods: Data were obtained from all US hospitals that contributed to the National Cancer Database (NCDB) between 2004 and 2013. Univariate and multivariate analyses was done to identify factors associated with patient outcome. Results: A total of 61,940 patients with stage IV CRC older than 18 years were identified. Mean age was 63.4 years (SD±14), with a male preponderance (54.8%). About 80% were Caucasian and 69.9% had colon cancer. Compared to medical treatment only, resection of both primary and metastatic sites (13.5%; HR 0.40; 0.37-0.44; p < 0.001), or primary site resection alone (49.2%; HR 0.52; 0.48-0.56; p < 0.001) were associated with improved overall survival (OS). Other co-variates associated with improved survival included younger age group, year of diagnosis (2009-2013), colon tumor location, and < 3 metastatic sites (Table). Five-year OS for resection of primary and metastatic site (28.2%) was higher than for primary site resection alone (14.9%) or no surgical treatment (4.7%). Conclusions: Resection of metastatic sites or primary tumor was associated with improved survival in patients with stage IV CRC.[Table: see text]
Clinical and molecular characteristics of non-small cell lung cancer patients from rural Maine.
Authors: Harb Antoine , Curtis Adam , Skacel Laura , Babcock Michael , Skacel Marek
Published: May 2019

e18237

Background: Non-Small Cell Lung Cancer (NSCLC) is the most common malignancy worldwide and the leading cause of malignancy-related mortality in the United States. The state of Maine in particular, has one of the highest rates of lung cancer in the country. Methods: We reviewed all NSCLC patients (adenocarcinoma (AC) and squamous cell (SC) histology) diagnosed between January 2017 and June 2018 at Northern Light Cancer Institute. 261 patients with clinical follow-up were identified. We correlated their clinical characteristics with molecular abnormalities identified by Next Generation Sequencing (NGS) and Fluorescence in situ hybridization, PD-L1 status by immunohistochemistry, disease-free and overall survival. Results: 210 patients had AC and 51 SC. They were evenly split between men and women. The median age at diagnosis was 68 years. 99% of patients were Caucasian. 15 patients were never smokers, the rest were equally divided between active and previous smokers. 44% had early stage disease (I/II) and 56% had late stage disease (III/IV) on presentation. 36.4% had a PD-L1 high status. The frequencies of the molecular aberrations identified in AC and SC are listed in the table below: Treatment differed by stage, including surgery/Radiation +/- adjuvant chemotherapy for early stage disease, definitive chemo-radiation followed by immunotherapy for stage III disease. Stage IV patients were treated with immunotherapy, combination chemo-immunotherapy, targeted therapy, palliative radiation and hospice referral. After a median follow-up of 10.6 months, overall survival (OS) was 66%. Disease free survival (DFS) was 33%. Using univariate (chi-square), multivariate (logistic regression) and Kaplan-Meier (log rank) analyses, we identified that in addition to a high clinical stage, which was associated with shorter OS and DFS, high PD-L1 status, and the presence of p53 mutation, were independent predictors of shorter OS, and p53 mutation of shorter DFS. Conclusions: NGS-based molecular testing deployed in real-time non-academic setting proved to be a valuable tool to identify therapeutic and prognostic targets in NSCLC. Besides those endorsed by the NCCN guidelines, p53 mutation is a common abnormality associated with adverse outcomes. While high PD-L1 expression is a desirable immunotherapy marker, its presence also predicted adverse overall outcomes in our patients.[Table: see text]
Impact of rates of referral and systemic therapy on 1-year outcomes in metastatic NSCLC: A real-world population based study.
Authors: Fundytus Adam Michael , Fu Yunting , Shack Lorraine , Pham Truong-Minh , Cheung Winson Y.
Published: May 2019

e18238

Background: EGFR/ALK inhibitors and immunotherapy represent promising treatments for metastatic NSCLC, but patients must be referred to a cancer center (CC) to be considered for these treatments. Local referral rates to a CC for advanced pancreatic cancer are only 51%. We hypothesized that rates of referral for stage IV NSCLC are also low, thereby affecting survival. Methods: Using linked data from the provincial cancer registry, oncology specific EMR, administrative claims and vital statistics, we identified all patients diagnosed with stage IV NSCLC from 2009 to 2016 in Alberta, Canada. Demographics, Charlson Comorbidity Index (CCI), method of diagnosis, year of diagnosis and site of metastasis were compared between patients referred vs not referred (NR) to a CC and between those who received systemic therapy (ST) vs those who did not. A multivariable piecewise constant hazard model was constructed to estimate the hazard ratio (HR) of death in the 1st year. Results: We identified 9717 stage IV NSCLC patients among whom 65.8% and 34.2% were diagnosed pre and post 2012. In this cohort, 6907 (71%) were seen at a CC. Factors which predict referral to a cancer center are: dx by cytology (OR 6.81, 95% CI: 5.99-7.75; p < 0.001) or histology (OR 6.29, 95% CI: 5.40-7.34; p < 0.001) vs radiologic dx; Age < 70 (OR 1.87, 95% CI: 1.69-2.07; p < 0.001); dx after 2012 (OR 1.52, 95% Cl 1.36-1.70; p < 0.001) and CCI≤1 (OR 1.50, 95% Cl 1.34-1.68; p < 0.001). ST was administered to 2057(21.2%). Factors that predict ST are: dx by cytology (OR 6.48, 95% CI: 5.18-8.11; p < 0.001) or histology (OR 6.35.18 , 95% CI: 5.02-8.04; p < 0.001); Age < 70 (OR 2.55, 95% Cl 2.33-2.82; p < 0.001); CCI≤1 (OR 1.56, 95% Cl 1.39-1.76; p < 0.001); dx after 2012 (OR 1.28, 95% CI: 1.16-1.41 and female gender (OR 1.18 , 95% CI: 1.07-1.29; p < 0.001; p < 0.001). Within the 1st year post dx, HR for mortality was lower both in patients referred to a CC vs NR (HR 0.3, 95%CI .28-0.31, p < 0.0001) and patients receiving ST vs no ST (HR 0.3, 95% CI .28-0.32, p < 0.0001). Conclusions: Close to 1 in 3 patients with stage IV NSCLC were not referred to a CC even though referral and receipt of ST were associated with a significantly lower risk of death in the 1st year following diagnosis. Clear delineation and wide dissemination of appropriate referral pathways are needed to improve outcomes, especially among older patients.
Meta-analysis of effect of hormone therapies on lipid levels in breast cancer patients.
Authors: Huang Hsin-Hui , Bertolet Marnie , Barinas-Mitchell Emma , Diergaarde Brenda , Chang Chung-Chou
Published: May 2019

e18243

Background: Breast cancer (BC) patients with hormone-sensitive tumors often receive adjuvant hormone therapy for an extended period. How this affects lipid levels is not known. This study evaluated the relationship between dyslipidemia, a cardiovascular disease risk factor, and use of adjuvant hormone therapy among breast cancer patients. Methods: Randomized clinical trials for adjuvant hormone treatment in post-menopausal BC patients without residual cancer after primary treatment that reported lipid levels were identified in PubMed and EMBASE (N = 13). Bayesian network meta-analysis for longitudinal data was used to evaluate each drug’s effect on the mean changes in lipid levels from baseline. Key covariates were examined to determine heterogeneity of treatment effects; consistency of estimates was assessed using the arm-based method. Results: Toremifene improved all lipids more than any other hormone drug studied (see Table). Most aromatase inhibitors (AIs) did not significantly impact lipids. Age, baseline lipid value, and prior usage of Tamoxifen modified the drug effects on most lipids. However, these modifications do not change the overall conclusion. Conclusions: Selective estrogen receptor modulators (SERMs) are beneficial to most lipid profiles, but AIs do not have consistent impacts on lipids. Tailoring hormone drug prescriptions based on medical conditions of BC patients is recommended. [Table: see text]
Online education about lung cancer immunotherapy: Outcomes over time.
Authors: Pender Lori Keys , Kadkhoda Haleh , Lucero Katie S. , Repetto Patti , Gearhart Jacqueline
Published: May 2019

e18249

Background: The indications and use of immune checkpoint inhibitors (ICIs) in the treatment of advanced and metastatic lung cancer have grown dramatically since the first lung cancer drug approval in 2015. The rapid pace of change can make it difficult for oncologists to stay up to date with how best to integrate these news agents into treatment paradigms. The objective of this study was to assess trends over time in oncologists’ knowledge, competence, and confidence using ICIs in the treatment of lung cancer. Methods: A series of online continuing medical education (CME) activities about the role of ICIs in lung cancer treatment was launched in April 2014; 28 included multiple-choice knowledge/competence questions and a confidence question assessed on a 5-point Likert-type scale before and immediately after the activity. Activities that had at least 30 oncologists participate pre/post are included in this analysis. A pre-/post-assessment study design was used, and educational effect was assessed with Chi-square tests. Analyses were conducted to examine trends in knowledge, competence, and confidence over four years on a quarterly basis. Weighted averages in each of the outcomes were calculated by quarter. Results: A total of 132,370 learners participated from April 2014-March 2018, including 61,761 physicians, of whom 19,439 were oncologists. The average increases pre- to post-test for knowledge- (25 activities), competence- (18 activities), and confidence-based (9 activities) questions were 16%, 12%, and 7%, respectively (P < 0.001 for all comparisons). The absolute increase in knowledge from pre-test in 2014 (41%) to post-test in 2018 (56%) was 14 percentage points; and for competence, 25% (from 28% in 2014 to 52% in 2018). The mean confidence rating pre-test in 2016 was 2.85 versus 3.16 post-test in 2018. Conclusions: Online CME improves oncologists’ knowledge, competence, and confidence using ICIs in the treatment of lung cancer at any given point in time; however, gaps remain, and given the wealth of new data that continue to emerge, on-going education is needed to reinforce and build upon existing knowledge, close persistent gaps, and increase oncologists’ confidence with this new therapeutic class.
The burden of hyponatremia and hypercalcemia on hospitalizations and mortality in lung cancer patients in the United States: An analysis of nationwide inpatient database.
Authors: Kamboj Sukriti , Kumar Varun , Mazurkivich Stephen , Acker Warren
Published: May 2019

e18256

Background: In 2018, there were over 234,030 patients diagnosed with lung cancer in the US with over 154,050 deaths. While the incidence continues to fall (mostly due to reduced tobacco consumption ), the mortality continues to be high with an overall median five year survival rate of only 19%. It is important to identify factors which are associated with worse outcomes in these patients. We aim to note the trends in patients hospitalized with lung cancer who have hyponatremia and hypercalcemia. Methods: We used the Nationwide Inpatient Sample (2002-2013) to identify lung cancer hospitalizations with hyponatremia and hypercalcemia. We analyzed trends in incidence, in-hospital mortality, length of stay (LOS) and cost. We calculated adjusted odds ratios (aOR) for outcomes including in-hospital mortality. Results: A total of 1,404,228 patients were studied with lung cancer were hospitalized from 2005-2014. A number of admissions has been progressively declining from 159,568 in 2005 to 123,305 in 2014 with a relative decline of 21.8%. The overall incidence of hyponatremia in these patients was 8.62%, and it has been trending up from 6.79% to 10.48% (p < 0.001) from 2005-2014 with a relative increase of 57%. Hypercalcemia was reported in 2.59 % of patients admitted with lung cancer. The number of hospitalizations in lung cancer patients with hypercalcemia has increased from 2.19% to 3.17% (p < 0.001) with a relative increase of 49.3%. Hospitalizations for hyponatremia and hypercalcemia were more frequent in age 50-64 years, males and smokers. Lung cancer patients with hyponatremia have in-hospital mortality of 12.9 % (OR 1.43, p < 0.001). Patients who have hypercalcemia have in hospital mortality of 17.1%( OR 1.15, p < 0.001). Conclusions: This study studies trends in hospitalizations in patient with lung cancer and incidence of hyponatremia and hypercalcemia. It is noted that hyponatremia and hypercalcemia are associated with increase the risk of in hospital mortality and increase cost of care in lung cancer patients. Utilization of these findings in guiding management may lead to decreased hospitalizations, hospital stays, and improve outcomes for these patients.
Anticancer therapy within the last 30 days of life: Results of an audit and re-audit cycle from a regional cancer center.
Authors: Nguyen Mike , Wann Alysson , Tamjid Babak , Sahu Arvind , Torres Javier
Published: May 2019

e18260

Background: The therapeutic landscape in medical oncology continues to expand significantly. Newer therapies, especially immunotherapy, offer the hope of profound and durable responses with more tolerable side effect profiles. Integrating this information into the decision making process is challenging for patients and oncologists. Systemic anticancer treatment within the last thirty days of life is a key quality of care indicator and is one parameter used in the assessment of aggressiveness of care. Methods: A retrospective review of medical records of all patients previously treated at Goulburn Valley Health oncology department who died between 1 January 2015 and 30 June 2018 was conducted. Information collected related to patient demographics, diagnosis, treatment, and hospital care within the last 30 days of life. These results were presented to a hospital meeting and a quality improvement intervention program instituted. A second retrospective review of medical records of all patients who died between 1 July 2018 and 31 December 2018 was conducted in order to measure the effect of this intervention. Results: The initial audit period comprised 440 patients. 120 patients (27%) received treatment within the last 30 days of life. The re-audit period comprised 75 patients. 19 patients (25%) received treatment within the last 30 days of life. Treatment rates of chemotherapy reduced after the intervention in contrast to treatment rates of immunotherapy which increased. A separate analysis calculated the rate of mortality within 30 days of chemotherapy from the total number of patients who received chemotherapy was initially 8% and 2% in the re-audit period. Treatment within the last 30 days of life was associated with higher use of aggressive care such as emergency department presentation, hospitalisation, ICU admission and late hospice referral. Palliative care referral rates improved after the intervention. Conclusions: This audit demonstrated that a quality improvement intervention can impact quality of care indicators with reductions in the use of chemotherapy within the last 30 days of life. However, immunotherapy use increased which may be explained by increased access and perceived better tolerability.
Non-clinical needs of cancer patients in Spain under different perspectives: A comparative study.
Authors: Cruz-Hernández Juan J. , Ruiz Isabel , Fernandez-Marcos Ana , Martin Rosana , Aranda Enrique , Carrato Alfredo , Díaz-Rubio Eduardo , Guillem Vicente , Lopez Rafael , Feyjoo Margarita , Ferrer Ramon , Gonzalez-Garcia Nerea , Nieto-Librero Ana , Gonzalo-Gomez Alicia , Camps Carlos
Published: May 2019

e18266

Background: Patients with cancer and their caregivers express unmet needs beyond the clinical approach to cancer. The ECO Foundation (Quality and Excellence in Oncology) and the Spanish Association Against Cancer (AECC) have promoted a qualitative research study with the objective to compare the perceptions of newly diagnosed and 2-3 years after diagnosis cancer patients, caregivers, oncologists, nurses and social workers in relation to a set of non-clinical needs expressed by cancer patients and caregivers, and to obtain concrete and feasible proposals for improvement aimed at satisfying these needs. Methods: A multidisciplinary group of experts developed a questionnaire containing information processes for cancer patients and caregivers, shared decision-making, healthcare circuits, the architecture of consultations, psychological support, support of associations and hospital social workers. Fourteen Medical Oncology Services of Spanish hospitals have participated in this study collecting 310 forms. Data were statistically analyzed using Fisher's exact test. Results: Information processes. The opportunity to have a second opinion is positively valuated for 72.6% of patients and 70.2% of caregivers. However, although 62.5% of oncologists referred to offer this option to their patients, only 10.9% of patients reported having received it. Shared decision-making. For 58% of oncologists, patients are sufficiently trained to share decision-making, but only 24.6% of newly diagnosed patients consider being prepared. In addition, although 95.8% of oncologists report offering the participation of their patients in decision-making, only 45.8% of newly diagnosed patients and 64.4% of 2-3 years after diagnosis patients, consider having received this opportunity. Psychological support. Psychological assistance was considered positive for 94.2% of the patients, 97.4% of the caregivers, 85.4% of the oncologists and 97.1% of the nurses. However, only 21.3% of oncologists and 31.4% of nurses recognize offering such proffessional care given by psychologists to patients. Conclusions: Knowing the non-clinical needs, not only of patients and caregivers, but also from the health care professionals, is essential when designing health strategies that should align the perceptions of patients and health care professionals.
Medication-related osteonecrosis of the jaw: Evidence for infection versus oversuppression.
Authors: Fleisher Kenneth Evan , Muggia Franco , Glickman Robert S
Published: May 2019

e18268

Background: Antiresorptive medications are important in maintaining bone health for patients with osteoporosis, metastatic cancer and multiple myeloma. Medication-related osteonecrosis of the jaw (MRONJ) may compromise quality of life and treatment of the underlying disease. There are many controversies regarding the pathogenesis, risk and management of MRONJ. Evidence-based data that suggest osteonecrosis of the jaw (ONJ) is triggered by infection and reports of ONJ unrelated to antiresorptive therapy (ART) have confounded previous hypotheses that pathogenesis is directly attributed to ART by oversuppression of bone remodeling. The aim of this study is to determine the outcome for management of MRONJ based on eradication of infection. Methods: The investigators designed a retrospective cohort study for patients who underwent surgical management of MRONJ. Identification of infected and necrotic bone was achieved via nuclear imaging (i.e., technetium bone scan, positron emission tomography), computed tomography and/or cone beam computed tomography. Surgical techniques included bone resection (i.e., marginal, segmental), local flap, reconstruction with microvascular free flap, and/or autogenous platelet graft. Perioperative modalities included hyperbaric oxygen therapy and culture-guided antibiotic administration. We recorded medical history, location of the MRONJ lesion, type of antiresorptive therapy and duration of perioperative antiresorptive therapy. The outcome variable was postoperative healing defined by mucosal closure without signs of infection or exposed bone at the time of follow-up including cases with complications related to subsequent dental infection or treatment. Descriptive statistics were calculated for successful management, medical history and duration of perioperative antiresorptive therapy. We excluded cases treated by palliative intent, when surgery was limited or contraindicated, and/or inadequate follow-up. Results: A total of 54 patients with 59 MRONJ lesions were evaluated (40 with cancer and 14 with osteoporosis). All patients were successfully treated with 13 patients continuing ART after surgery (average follow-up 10 months) and 8 patients requiring more than 1 surgery for lesions associated with osteosclerosis. Conclusions: This study suggests that MRONJ is an infection-driven process that can be managed with various modalities to control diseased bone and facilitate healing. Patients may resume ART following successful management of MRONJ.
Delay in diagnosis and treatment of gastrointestinal cancer in Nepal.
Authors: Dulal Soniya , Paudel Bishnu D. , Shah Aarati , Acharya Bibek , Acharya Sandhya Chapagain , Thapa Rameej Revanta , Wood Lori
Published: May 2019

e18269

Background: Gastrointestinal (GI) cancers represent a major health challenge worldwide including Nepal where patients (pts) often present with advanced disease. The purpose of this study was to determine the time delay in diagnosis and treatment by evaluating time from first symptoms to diagnosis and treatment and to identify contributing factors from both pts and the health system in Nepal. Methods: An IRB approved cross sectional study was performed in pts with GI cancers. 50 newly diagnosed pts were enrolled and interviewed with a standardized questionnaire during the last 6 months of 2018. Diagnosis delay was defined as time from first symptoms to histopathological diagnosis. Treatment delay was defined as time from diagnosis to surgery and/or treatment by medical/ radiation oncologist. Results: The median age at diagnosis was 52.5 years. 52% had gastroesophageal cancer and 48% had colorectal cancer. 84% presented with Stage III/ IV disease. The median diagnosis delay was 217 days and the median treatment delay was 37 days. The median patient delay (time from first symptoms to first medical consultation) was 150 days. 64% were illiterate, 94% had a history of self medication prior to first medical consultation, 68% were from rural areas with limited healthcare facilities and 72% were unaware of causes of GI cancers. Reasons for diagnostic delay appear to be self diagnosis, self medication and lack of a prompt referral system. Reasons for treatment delay included financial constraint, prolonged wait times for procedures and treatment due to limited skilled manpower. Conclusions: Our data shows there is a significant delay in diagnosis and treatment especially in the time from first symptoms to first medical consultation. We found many preventable reasons for this that, if addressed appropriately, could have a significant impact on reducing the morbidity and mortality of GI cancers. There is an urgent need for intensive and comprehensive cancer education in Nepal and other developing countries.
A physician-led team approach to improve advance directive completion rates in an inpatient oncology unit.
Authors: Konda Manojna , Ananthula Aneesha , Baltz Alan , Pandey Yadav , Atwal Dinesh , Makhoul Issam , Moore Heather C
Published: May 2019

e18271

Background: Advance care planning (ACP) ensures that patients receive care which is consistent with their beliefs and preferences. Advance directive (AD) completion is an important part of this process, but there is much room for improvement as the AD completion rates in oncology patients have been reported to be as low as 10%. We sought to improve the AD completion rates in the inpatient oncology unit in our institution by undertaking an 8-week quality improvement project. Methods: Using a Plan-Do-Study-Act (PDSA) methodology, a multidisciplinary team lead by residents was created to review the process. 2 cycles of PDSA were conducted over a period of 8 weeks. Electronic medical record (EMR) was reviewed each morning, new patients admitted to oncology unit were identified, and those without AD on file were educated by a designated resident about the importance of completing AD. Based on the patients’ willingness, the case manager was alerted with daily communication to follow-up, provide more information and assistance to file the AD. The AD completion rates were tracked daily and communicated to the team through an e-mail. Results: Only 8.3% of hospitalized oncology patients had completed AD prior to our intervention. PDSA cycle 1 resulted in improving the AD completion rates to 28.9%. Barriers were identified after cycle 1 and were overcome by clarifying the role of each team member, addressing inconsistencies in AD filing, uploading into EMR and making the scanned AD easily accessible. After implementation of the above measures, PDSA cycle 2 resulted in improving the AD completion rates to 40.9%. Conclusions: Designating a person to take lead of a multi-disciplinary team, addressing the inconsistencies in the process and keeping a daily track through EMR can lead to an improvement in AD completion rates. Sustainability of this projects remains to be tested. However, there is a room for further improvement.
Detection of the burnout syndrome, empathy, and psychosocial profile of the health team of the oncology service, UANL University Center Against Cancer (CUCC).
Authors: Alcorta-Garza Adelina
Published: May 2019

e18274

Background: The Burnout Syndrome, a set of somatic and behavioral signs given by the physical and mental exhaustion that arises from the workings of a person. In particular, health personnel in the oncology area have been exposed to this syndrome. Occupational exhaustion can affect the quality of life of individuals, in a way that also affects their performance at work. Also the staff burnout damages the attention given to the patient, so that the latter can also perceive it. Therefore, it is a priority in our center to determine the frequency and severity of exhaustion among the staff of the Oncology Service and its association with the quality of self-reported empathy towards patients. Methods: It is an observational, cross-sectional and correlation study. With the informed consent of the subjects, questionnaires were applied to assess the subjet´s psychosocial profile, the presence or absence of work exhaustion (Maslach), and empathy. A database was collected with the results obtained from validated questionnaires. The instruments were applied to 1060 staff members working in the Oncology Service of the CUCC, including physicians, students, nurses and administrative health personnel. Results: Among the sample, 413 (38.96%) Burnout cases were found. The age range was from 18 to 61 years. The most prevalent subscale was personal fulfillment with 247 cases, followed by depersonalization with 199 cases, and finally, emotional fatigue with 94 cases. When analyzing the Burnout cases according to their severity, 313 (29.52%) presented a subscale, 73 (6.88%) presented two and 27 (2.54%) presented three (% based on the total of n). The most affected age group was between 20 and 51 years old and, in general, had a higher level of Burnout than women (56.65 vs 43.35%). Regarding the type of personnel, the students showed a higher prevalence (402/1001, 40.15%) than the workers (11/59, 18.64%). As a group, there is a greater loss of empathy in association with burnout. For men and students, the severity and presentation of exhaustion are greater than for workers and non-workers. Conclusions: Among the other variables, the most correlated with the Burnout syndrome were empathy, the general health questionnaire and family malfunction. among others. We suggest starting a special program to help vulnerable staff for their own quality of life and a better service for patients.
Knowledge, attitude and practice in cancer pain management: A survey study among attending physicians, residents and nurses.
Authors: Ning Ying , Ackula Haritha , Jindal Vishal , Li Mu , Li Pengyang , Siddiqui Ahmad Daniyal
Published: May 2019

e18278

Background: Our study used KAP model to evaluate differences of Knowledge, Attitude, and Practice regarding cancer pain management among care providers in a community teaching hospital. Methods: A 32-question KAP survey was designed with 3 demographic, 15 Knowledge, 9 Attitude and 5 Practice questions. It was administered randomly and anonymously to attending physicians of medicine, medical residents and medical nurses. 106 effective questionnaires (24 attending, 41 residents and 41 nurses) were analyzed and compared with percentage by Chi-Squared Test using SPSS 25. Results: Majority of all 3 groups believe only 50-60% of cancer pain can be effectively managed, while the actual effectiveness is close to 90% with proper management. Demographically, female predominates in nurses as expected, there is no statistical difference in previous pain/palliative education. Years of experience vary considerably (P < 0.001). Attending perform best in Knowledge (60% correctness), but not statistically better (P = 0.361), a common area of weakness is low awareness of alternative management besides medication. Attending and nurses have more positive attitude compared to residents (P = 0.002). Nurses perform best in Practice mainly demonstrated by higher awareness and consistency in pain evaluation and documentation (P < 0.001). Finally, overall performance is consistent with self-reported confidence. Conclusions: Knowledge is relatively easy to acquire since residents have comparable level to attending, although further education is indicated for all the providers. More care experience and a positive attitude better predicts practice performance. All 3 group seems to lack belief and confidence in effective cancer pain management, another area to be addressed for quality improvement. [Table: see text]
Are the nonmedical needs of cancer patients satisfied adequately.
Authors: Rucinska Monika , Osowiecka Karolina , Sroda Radoslaw , Saied Arian , Milobedzka Magdalena , Miloszewski Jakub , Korzeniewicz Martyna , Oraczewski Rafal , Szwiec Marek , Mangold Sarah , Paszkowska Elzbieta , Osuch Dominika , Nawrocki Sergiusz
Published: May 2019

e18283

Background: Cancer is a global health care problem. Cancer disease is not only medical problem, there are a lot of areas in human life that cancer has influence on. The rationale for this study was to identified non-medical needs among cancer patients during treatment and assessment of who helps patients. Methods: The study was carried out on a group of 346 patients who were being treated for malignant neoplasm in five oncological centers in Poland. A questionnaire was prepared specifically for this study and each patient was interviewed individually. The questionnaire was validated on a group of 20 patients. The study protocol was approved by the Local Ethics Committee of the University of Warmia and Mazury in Olsztyn, Poland. All of the participants had submitted a signed consent form. Results: There were analyzed 164 women and 180 men (2 no date), median age 65 years. 79% of patients could have hoped for psychological support, most of them received psychological support from partner/family (88%) and friends (31%), less from psychologist (28%) and priest (5%). Half of patients (52%) had a need for social support, 42% of them received social support from partner/family, 12% from friends and only 7% from a social worker. One third of patients (30%) received support from a dietician. The help from a physiotherapist were given to 20% of patients. In the analysis of different factors it was noticed that women more often than men got help from psychologist and physiotherapist (p < 0.05). Some of patients (16%) did not know that they could get help in their non-medical needs. 80% of analyzed patients thought they need someone who would help them with the non-medical problems during their cancer disease. Conclusions: Cancer patients have some non-medical needs, but only a small part of them receives professional support. The proper solution could be a special person who may notice patients problems and coordinate professional support.
Analysis of a neurosurgical directed acute spinal cord compression pathway at Michigan Medicine, a tertiary referral hospital.
Authors: Krauss John C. , Klarr Daniel
Published: May 2019

e18285

Background: Spinal cord compression (SCC) is considered an oncologic emergency that is likely to severely impair patients’ quality of life if immediate action is not taken. Clinicians need a high suspicion to diagnose SCC, as the presenting symptoms are variable and nonspecific. To expedite the diagnosis and treatment of SCC, we instituted an emergent spine MRI imaging pathway that was led by the neurosurgeons and involved close collaboration with medical oncology and radiation oncology. Methods: The charts of all patients from July 2015 to June 2018 who underwent the “MR Spine Cord Compression Acute” imaging pathway at Michigan Medicine were reviewed. Electronic time stamps provided the time of the initial order, the time to scan completion, the time to scan reading, and the time to definitive intervention. The charts were reviewed for the initial neurosurgical physical exam, a presentation consistent with recent trauma, a previous diagnosis of malignancy, and a previous diagnosis of bone metastases. The type and timing of therapy, and survival following the imaging protocol were assessed. Results: 319 unique MRI exams were done over the three-year span, 155 of the patients had cancer, and 75 patients had SCC. The time from ordering of exam to performance is 2.91 hours (0 to 25.45), from performance to read 8.31 hours (0 to 75.25 hours). Time from MRI to intervention was 63.14 hours (0 to 432 hours) based on complex decision making around surgical vs. radiation vs. medical therapy. For the majority of patients who were diagnosed with SCC, the cause was secondary to tumor growth from contiguous spinal metastasis, and most had previously identified bone metastases. Degenerative disc extrusion was the most common cause of benign SCC. Conclusions: A neurosurgical directed standard imaging protocol is effective at rapidly diagnosing SCC. Malignant SCC is predominately treated surgically, but complex multi-disciplinary patient centered decision-making involving neurosurgery, radiation oncology, and medical oncology is frequently necessary to arrive at the appropriate treatment.
Swallow screen and test in cancer patients.
Authors: Shrotriya Shiva , Abro Calvin , Rous Fawzi Abu , Trimmer Rosemary , Sharma Mukta , Rayamajhi Supratik , Estfan Bassam N. , Walsh Declan
Published: May 2019

e18288

Background: Swallowing is a complex process with four phases. It initiates digestion and is essential for proper nutrition. Difficulty swallowing independently correlated with cancer survival. We retrospectively evaluated the prevalence and incidence of difficulty swallowing in an acute care palliative medicine unit. BMI and survival were also examined. Methods: Electronic Medical Records (EMR) 2010-2012 was reviewed. Assessment comprised of 3 steps: nurse survey on patient condition (coma, intubation, PEG/feeing tube, respiratory distress), screening questionnaire and clinical swallowing test. Change in BMI from the day of admission to discharge calculated. Survival calculated from EMR and Social Security Death Index. Results: N = 261 with cancer identified; 47% known metastases. The mean age (± SD) was 68 ± 13 years. 55% females. 71% Caucasians and 25% African Americans. It was common in lung, gastrointestinal (GI) and genitourinary (GU) cancers. Clinical swallowing test was indicated in 94%. Prevalence of difficulty swallowing = 6%. Incidence of difficulty swallowing = 21%. Change in Body Mass Index (BMI) from 26 ± 7 (Mean ± SD) to 26 ± 6 on admission to discharge respectively. Median (25th, 75th percentile) survival: 25(13, 62) days. Conclusions: Difficulty swallowing was common in lung, GI and GU cancers. The incidence of difficulty swallowing in acute care palliative medicine unit was 21% and prevalence 6%. 75% with difficulty swallowing identified by nurse’s initial survey, 19% through screening questionnaires and 6% clinical swallowing test. Pneumonia/respiratory and GI problems were common. Swallowing evaluation critical for comprehensive cancer care.