bluuebunny/crossref_metadata_2025 huggingface dataset:
National guidelines for the best practices in palliative and end-of-life care for lesbian, gay, bisexual, and transgender cancer patients and their families.
Authors: Maingi Shail , O'Mahony Sean , Bare Michael G , Margolies Liz , Scout Nfn , Kamen Charles Stewart
Published: February 2017

126

Background: A growing body of evidence indicates that LGBT communities are disproportionately affected by cancer due to higher rates of traditional risk factors such as tobacco and alcohol, non-inclusion in educational campaigns, and minority stress. Due to the exclusion of sexual orientation and gender identity measures in national oncology databases, there has been difficulty documenting the extent of healthcare disparities that exist for LGBT cancer patients. However, an increasing number of studies describe the experiences of LGBT patients and their families at the end of life. Although societal attitudes and legal protections are shifting, the existing literature clearly indicates that LGBT patients in palliative and end-of-life care settings encounter unique barriers to quality care. For example, LGBT individuals may distrust specific members of palliative care teams, such as a pastor because of past rejections by faith-based communities. Other barriers include high levels of familial rejection, fear of revealing minority status, and a lack of legal protection. Methods: In 2014 and 2015, a CDC-funded multidisciplinary expert panel met to develop the best practices across the cancer care continuum for the LGBT community. The experts drew on available literature and clinical and community experience. They reached a consensus regarding recommendations that were later reviewed using a process that elicited comments from providers, patients, and community and national organizations. Results: Recommendations were made in 7 domains: 1) cancer prevention, 2) cancer screening, 3) diagnosis, 4) treatment, 5) survivorship, 6) palliative and end-of-life care, and 7) public health. Here we report the panel’s recommendations for improving palliative and end-of-life care for LGBT cancer patients. Conclusions: The barriers for LGBT cancer patients to access quality palliative and end-of-life care exist, and the subsequent healthcare disparities are often invisible to healthcare providers. Implementation of these national recommendations will help eliminate the disparities that LGBT patients and their families experience when facing cancer.
An interdisciplinary early simultaneous palliative approach in advanced lung cancer (a-LC): Preliminary data in outpatient setting experience.
Authors: Catino Annamaria , Aloe Ferruccio , Piccininno Maria Elvira , Daniele Antonella , Misino Andrea , Ricci Donata , Damiani Basilio , Cormio Claudia , Logroscino Antonio , Galetta Domenico
Published: February 2017

138

Background: To integrate Simultaneous Palliative Care with standard cancer care is a growing-interest concept; hence, a global patient-centered care rather than disease-directed intervention is a major issue in advanced Lung Cancer (a-LC). These patients are often characterized by high tumor burden and comorbidities related to smoking history and elderly; furthermore, malnutrition could contribute to worse outcome. Some landmark experiences have demonstrated that a-LC patients benefit from simultaneous palliative care in early phase of treatment. The initial results of a pilot experience on early simultaneous interdisciplinary palliative approach in a-LC patients, referring to the Thoracic Oncology outpatient department of a Clinical Cancer Center, are reported. Methods: From October 2014 to May 2015, 35 patients with stage IV disease, receiving first-line therapy, were accrued. The team includes medical oncologists, a palliative care specialist, a psychologist, a nutritional expert and a research nurse. The baseline assessment comprised the disease status and comorbidities, psychosocial distress, pain and Mini-nutritional assessment (MNA). Smoking habits were recorded and information about smoking cessation programs was provided. A survey about the grade of satisfaction of patients during this multimodal approach was conducted. Results: The main patients’ characteristics are shown in Table.18/35 patients required pain treatment reassessment, while 13/35 patients had severe malnutrition. The most frequent symptoms were pain (24/35), severe psychological distress (24/35), asthenia (23/35) and anorexia (20/35). Conclusions: This approach is suggested due to multiple unmet needs of these patients; these preliminary data confirm that an interdisciplinary early palliative care is feasible in an outpatient setting with good compliance and satisfaction of patients as well as of caregivers. [Table: see text]
The utilization of chemotherapy and radiation at the end of life in individuals with metastatic non-small cell lung cancer.
Authors: Stavas Mark J. , Martin Sara F. , Phillips Sharon E. , Perkins Stephanie Mabry , Shinohara Eric T.
Published: February 2017

143

Background: Advancements in the diagnosis and treatment of metastatic non-small cell lung cancer (NSCLC) have contributed to improved quality of life and survival. However, these successes are matched with rising healthcare costs and a growing debate over the appropriate utilization of medical resources near the end of life. To date, the majority of utilization studies report outcomes based on single institution or Medicare models. This may lead to significant bias due to individual physician preferences, narrow age groups or single payer systems. The purpose of this study is to analyze the broader trends and variables impacting the use of chemotherapy (CHT) and radiation (XRT) in the final months of life. Methods: The Florida Cancer Data System (FCDS) was used to evaluate patients with Stage IV (M1) NCLC from 1995 to 2010. Logistic Regression was used to determine the association between insurance types, census-based socioeconomic status (SES) and demographic variables with XRT received or CHT received. Results: 48,858 patients were identified within the FCDS and eligible for this study. The median age was 69 years. The median survival was 4.8 months. The overall use of XRT decreased between 1995 and 2010 from 52% to 37%, while the use of CHT increased from 35% to 49%. The utilization of treatment during the final 60, 30 and 14 days of death was 28%, 13% and 5% respectively for XRT, and 18%, 8% and 4% for CHT. Neither insurance status (OR, 0.852; 95% CI, 0.721 -1.174) nor poverty status (OR, 1.026; 95% CI, 0.950 -1.109) was predictive for XRT received. Those classified as low SES (OR, 0.685, 95% CI, 0.633-0.741) or not insured (OR, 0.678, 95% CI, 0.572-0.804) were less likely to receive CHT. Older-unmarried-females were less likely to receive CHT and XRT compared to their younger-married-male counterparts. Conclusions: When examining a broader demographic and insurance mix, the utilization of XRT and CHT in the final 30 and 14 days of death remain low at 13% and 5% for radiation and 8% and 4% for chemotherapy consistent with previously reported studies. Younger-married-males were more likely to receive palliative treatments. Insurance and SES did not influence the delivery of XRT while they did impact the use of CHT.
Multidisciplinary cancer conferences as a forum for early identification of patients who can benefit from palliative care.
Authors: Wright Frances Catriona , Johal Hardeep , MacKinnon Marnie , Arthurs Erin
Published: February 2017

148

Background: Introducing palliative care early in the cancer journey results in a better quality of life, less aggressive care and longer survival compared to patients receiving standard care. The INTEGRATE Project goal is to identify and manage patients who can benefit from palliative care using the UK Gold Standards Framework Surprise Question (would you be surprised if this person died within the next year?). Multidisciplinary cancer conferences (MCCs) are scheduled meetings for oncology teams to prospectively discuss patient diagnostic tests and treatment options, which were leveraged for the INTEGRATE Project. Methods: A pilot study to test the efficacy of the Surprise Question at MCCs and implementation of a palliative model of care has been implemented in 3 academic and 1 non-academic cancer centres. A survey was completed to identify provider comfort levels in providing palliative care. All sites completed Pallium Canada’s LEAP Onco module, which equips providers with skills to provide primary level palliative care. Patients identified at MCCs received advance care planning, symptom management, referrals and standardized reporting to primary care. Results: Four disease sites (Lung, GI, CNS and Head & Neck) are participating. A baseline survey showed over 50% of providers had no training in palliative care. 161 providers participated in LEAP Onco. Implementation of the Surprise Question at MCCs began in February 2015. Two months of implementation identified 39 patients at the CNS, Lung and GI disease sites out of 108 of patients reviewed. At the CNS MCC, 100% glioblastoma patients were identified. The Lung and GI disease sites had lower identification rates (27% and 10%, respectively). Identified patients will have their healthcare utilization (referrals to community providers, billing patterns, ER visits) analyzed to determine impact of this project. Implementation continues until 2016. Conclusions: MCCs appear to be an excellent forum for identifying patients who can benefit from a palliative approach to care within the CNS, Lung and GI site groups. Further data is being collected to inform provincial recommendations for broader implementation of palliative care in Ontario.
Impact of an initial supportive oncology clinic visit on hospitalizations and emergency department visits.
Authors: Curseen Kimberly A. , Gunter Debbie , Harrell Gwendolynn , Prizer Lindsay Penny , Moulia Danielle , Quest Tammie E.
Published: February 2017

150

Background: Hospitalizations and emergency department (ED) visits can be frequent, costly and discordant with stated goals-of-care for cancer patients. Little is known about the impact of outpatient palliative care and supportive oncology on hospitalizations and ED visits. Our aim was to investigate the impact of an initial visit at an outpatient supportive oncology clinic (SOC) on patient hospitalizations and ED visits. Methods: New patients were referred to a SOC from our health system’s oncologists from November 1, 2014 through January 31, 2015. Visits include a structured symptom assessment and personalized treatment plan from the clinic’s physician and/or nurse practitioner. Data were collected 90 days retrospectively and 90 days prospectively from 134 consecutive initial SOC visits. Descriptive statistics were calculated. We used the Wilcoxon signed rank test to compare the mean number of hospitalizations and ED visits in the 90 days prior and 90 days post a patient’s first SOC visit. Results: Mean patient age at first SOC visit was 55.6 (SD = 16.4). 51.2% of patients were female. The most common cancers were breast, lung, head and neck. Mean number of hospitalizations per patient was significantly (p < 0.05) decreased: 1.3 (SD = 1.6) in the 90 days prior to initial SOC visit vs. 0.7 (SD = 0.7) in the 90 days post initial SOC visit. There was a non-significant reduction in mean ED visits per patient: 0.9 (SD = 0.9) in the 90 days prior to initial SOC visit vs. 0.7 (SD = 0.7) in the 90 days post initial SOC visit. Conclusions: Hospitalizations were significantly decreased and ED visits were reduced after the first visit to a small-scale SOC. This provides evidence that outpatient supportive care including aggressive symptom management may reduce patient crises, preventing ED visits and hospitalizations, and will likely lead to cost savings and improve quality of life for patients during and after cancer therapy. The decrease in hospitalizations and ED visits may be underestimated if disease was progressing and overestimated if disease was shrinking, but this data was not available for this study.
Validation of the "surprise question" in gynecologic oncology: Comparing physicians, advanced practice providers and nurses.
Authors: Lefkowits Carolyn , Chandler Chelsea , Sukumvanich Paniti , Courtney-Brooks Madeleine , Duska Linda R. , Althouse Andrew , Kelley Joseph L
Published: February 2017

151

Background: The “surprise question” – “Would you be surprised if this patient died in the next year?” has been validated in non-gynecologic cancer as highly predictive of 12-month mortality. It has been used as a major inclusion criterion in studies showing benefit to specialized palliative care. It has not been studied in the gynecologic oncology (GO) population or with non-physician providers. Our objectives were to (1) evaluate the prognostic significance of the surprise question in GO patients and (2) compare the performance of the surprise question among different provider groups. Methods: The surprise question was asked of a group of 18 GO providers from a single academic institution (7 physicians, 7 advanced practice providers (APP) and 4 chemotherapy nurses (RN)) regarding their patients currently receiving radiation or chemotherapy. Demographic and clinical data were abstracted from chart review and mortality data was collected 12 months later. Results: The 263 patients included had a median age of 64 and the majority were white (94%). The most common cancer was ovary (50%), 58% had stage III/IV disease and 46% had recurrent disease. There were 54 deaths (20.5% one-year mortality). Risk of mortality was significantly higher for patients with a response of “No” to the surprise question from the MD (40% vs 10.6%, p < 0.01), APP (43.2% vs 7.6%, p < 0.01) and RN (50.8% vs 13.1%, p < 0.01). The unadjusted odds ratio for death within a year associated with a “No” answer to the surprise question by provider were as follows: MD OR 5.6 (p < 0.001), APP 9.21 (p < 0.001), RN 6.86 (p < 0.001). The APP group had the highest sensitivity (79.5%), while the RN group had the best specificity (75.6%). Conclusions: The surprise question is a simple, feasible and effective tool to identify patients with gynecologic cancer who have a greatly increased risk of 12-month morality when administered by physicians, advanced practice providers or chemotherapy nurses. This one question screen could be used to identify patients appropriate for early referral to specialized palliative care or patients in whom to consider initiating conversations about goals of care and advanced care planning.
Trends in health care utilization, cost, and aggressive care at end of life among older cancer patients in the Deep South.
Authors: Kvale Elizabeth Ann , Rocque Gabrielle , Bevis Kerri S. , Acemgil Aras , Taylor Richard A. , Demark-Wahnefried Wendy , Kenzik Kelly , Li Yufeng , Meneses Karen , Martin Michelle , Fouad Mona N. , Pisu Maria , Partridge Edward E.
Published: February 2017

155

Background: Healthcare utilization and costs escalate near diagnosis and in the final months of life. There is a national trend toward aggressive care at end of life (EOL). We examined patterns in utilization and cost across the trajectory of care and during the last two weeks of life during implementation of a lay navigation intervention. Methods: Claims data were obtained for Medicare beneficiaries ≥ 65 years old with cancer in the UAB Health System Cancer Community Network (UAB CCN). For 10 quarters from January 2012 -June 2014, we examined healthcare utilization for the population at large, navigated patients, and decedents. All analyses included ER visits, hospitalizations, and ICU admissions and use of chemotherapy in the last 2 weeks of life, and hospice utilization (admission or less than 3 days of hospice) in the quarter of death for decedents. Descriptive analyses and linear regression were used to test trends over time; general linear models evaluated changes in health care utilization and cost. Results: Across the population reduction of 13.4% to 11% for hospitalization (18% decrease, p < 0.01), 8.0% to 7.1% for ER visits (12% decrease, p < 0.01), 2.9% to 2.5% for ICU admissions (14% decrease, p = 0.04) and an increase of 3.9% to 4.3% for hospice (9.2% increase p = 0.37) were found. Among 5,861 decedents, in the last 2 weeks of life, there were decreases in ICU admissions (14.6% decrease, p = 0.11), from 39.2% to 32.0%, ER visits (18.4% decrease, p = 0.03), and chemotherapy, from 4.7% to 3.5% (25.5% decrease, p = 0.11).Over the 10 quarters, hospice enrollment increased from 70.7% to 77.4% (9.48% increase; p = 0.06), and the proportion of patients on hospice for less than 3 days changed from 7.8% to 7.5% (3.85% decrease, p = 0.30). Costs decreased about $158 per quarter per beneficiary. A significant pre-post decrease of $952 per beneficiary (p < 0.01) led to an estimated reduction in Medicare costs of $18,406,920 for the 19,335 beneficiaries in the UAB CCN for the five quarters post-implementation. Conclusions: We observed decreased healthcare utilization and cost and trends toward decreased aggressive care at EOL in the UAB CCN. Further work is needed to determine the impact of navigation on utilization trends.
The impact of a one month palliative care rotation on medical residents working in a tertiary cancer center in Jordan.
Authors: Shamieh Omar M. , Alawneh Alia , Ahamd Wafa , Salmany Sewar S , Altamimi Barakat , Alkam Hamzah , Dibs Khaled Nabil , Mallah Osama , Ammar Khawla , Turfa Rim , Abdel-Razeq Hikmat , Hui David
Published: February 2017

168

Background: Palliative care education and training remains inadequate for medical professionals especially in developing countries. We evaluated the impact of a one month palliative care clinical rotation on medical residents’ attitude, competency, and knowledge related to palliative care in a tertiary cancer center in Jordan. Methods: All transitional Internal Medicine residents rotated in a monthly palliative care rotation at King Hussein Cancer Center (KHCC), in Amman, Jordan, were requested to participate in this educational intervention study. A concise curriculum in palliative and end of life care, adapted from the Education for Physicians on End-Of-Life Care (EPEC) Curriculum and delivered by our faculty was piloted as a part of the clinical rotation. Residents spent one month in the inpatient palliative care unit, in addition to 10 hours of classroom interactive sessions. The curriculum comprised of five modules: 1- Principles of palliative care, 2- Pain management, 3- Management of distressing symptoms, 4- Communication skills, 5- End-of- life care. To assess our educational outcomes, we adapted a previously developed instruments by David Weisman and used by the National Residency Education in the United States. All Instruments were completed by each resident before and after the rotation, and included self-assessment of attitude, competency and a knowledge test comprising of 32-items of multiple choice questions. Results: Twenty of 27 (74%) residents who started the palliative care rotation completed the required education and had paired evaluations. There was improvement in all three instruments: 37% improvement in competence (p < 0.0001), 17% Improvement in knowledge (p = 0.015), and 5% improvement in attitude (p = 0.02). Conclusions: The one-month mandatory rotation improved knowledge, attitude and competence related to palliative care for medical residents.
Leaning upon international directives for optimization: Anemia—Results of the French Lidoanemia-2 Survey.
Authors: Launay-Vacher Vincent , Janus Nicolas , Ludwig Lisa , Deray Gilbert , Scotte Florian
Published: February 2017

180

Background: Anemia in cancer patients is common. The LIDOANEMIA-1 survey [Scotté F. MASCC 2015] reported that French clinicians do not follow EORTC guidelines. We aimed at improving EORTC guidelines dissemination among French physicians (FP). This second survey aimed at assessing the impact of our initiative on physicians’ behavior. Methods: Declarative survey conducted in France. The intervention consisted of having physicians watch a short video summarizing EORTC guidelines and their main messages for clinical practice. Evaluation of the impact of the intervention was performed with a 4-question web-based form FP filled in after seeing the video. Results: 319 FP answered the survey. Results are showed in the Table regarding the 4 main items: anemia diagnosis, Hb cut-off for considering RBC transfusion or ESA initiation, and Target Hb level on treatment. Among FP who were not following the guidelines, 67.7, 38.2, 50.8 and 65.2% declared they will follow them after the intervention, respectively for anemia diagnosis, Hb cut-off for considering RBC transfusion or ESA initiation, and Target Hb level on treatment. After the intervention, the expected proportion of FP who will follow EORTC guidelines is 93.2, 69.4, 82.6, and 89.4%, respectively for each item evaluated. Conclusions: Dissemination of guidelines is key to improve patient care. We tested a simple mean of presentation of EORTC guidelines in anemia management in cancer patients which significantly increased the proportion of FP who declare they will follow the guidelines. However, a non-negligible proportion of them does not agree and will not follow them, especially for the Hb cut-off for considering RBC transfusion. [Table: see text]
The Opioid Rotation Ratio (ORR) to transdermal fentanyl (TDF) in cancer patients.
Authors: Reddy Akhila Sunkepally , Haider Ali , Tayjasanant Supakarn , Wu Jimin , Liu Diane D , Yennu Sriram , De la Cruz Maxine Grace , Vidal Marieberta , Reddy Suresh K. , Bruera Eduardo
Published: February 2017

181

Background: Cancer patients frequently undergo opioid rotation (OR) for uncontrolled pain or opioid induced neurotoxicity. TDF is one of the most common opioids prescribed to cancer patients. However, the accurate ORR from other opioids to TDF is unknown and various currently used methods result in a wide variation of ORRs. Our aim was to determine the ORR of morphine equivalent daily dose (MEDD) to TDF when correcting for MEDD of breakthrough opioids (net MEDD) in cancer outpatients. Methods: We reviewed records of 22,532 consecutive patient visits at our Supportive Care Center in 2010-13 for OR from to TDF by a palliative medicine specialist. Data regarding Edmonton Symptom Assessment Scale (ESAS) and MEDD were collected in patients who returned for follow up within 5 weeks. Linear regression analysis was used to estimate the ORR between TDF dose and net MEDD (MEDD prior to OR minus MEDD of breakthrough opioid used along with TDF after OR). Successful OR was defined as 2-point or 30% reduction in pain score and continuation of the new opioid at follow up. Results: 129 patients underwent OR to TDF from other opioids. The mean age was 56 years, 59% male, and 88% had advanced cancer. The median time between OR and follow up was 14 days. Uncontrolled pain (80%) was the most frequent reason for OR and 59% had a successful OR with significant improvement in ESAS pain, constipation, and symptom distress scores. In 101 patients with OR and no worsening of pain at follow up, the median ORR (range) from net MEDD to TDF mg/day was .01 (-0.02-0.04) and correlation of TDF dose to net MEDD was .77 (P < .0001). The ORR was not significantly impacted by variables such as mucositis, serum albumin, and body mass index (BMI). The ORR of .01 suggests that MEDD of 100mg is equivalent to 1mg TDF/day or 40mcg/hour TDF patch (1000mcg/24hours). Conclusions: The median ORR from MEDD to TDF mg/day is .01 and the ORR from MEDD to TDF mcg/hour patch is 0.4. Further validation studies are needed. [Table: see text]
Breathlessness and opioid therapy: A retrospective chart analysis in 2,958 patients.
Authors: Gronwald Benjamin , Wolff Michael , Gaertner Jan , Bialas Patric , Niewald Marcus , Schmitz Andrea , Faehndrich Sebastian , Gottschling Sven
Published: February 2017

192

Background: Breathlessness is a common and distressing symptom, which increases in many diseases as they progress and is difficult to manage. It is widely accepted that opioids are safe and effective for treating dyspnea, although no single opioid has an authorization for the treatment of breathlessness. The aims of the study were to assess prevalence rates of breathlessness as well as the treatment approaches especially with respect to opioid therapy in all patients cared by a hospital palliative care team in a university hospital over a period of five years. Methods: A systematic review of all electronically available records of patients under palliative care service from April 2010 – April 2015 was performed. Results: Breathlessness was the third most common symptom in our patient group behind fatigue and pain. Furthermore it was classified as the utmost distressing symptom of all. Many patients suffering from breathlessness were opioid-naive before contact with our palliative care team. Many of these patients were put on prolonged-release opioids together with short-acting opioids (mucosal fentanyl) as rescue medication for breathlessness. Opioid therapy was judged to be very effective by the majority of patients suffering from breathlessness however caused (cancer-related or due to a benign disease e.g. chronic obstructive pulmonary disease). Conclusions: In a large cohort of patients breathlessness is a major topic and is clearly positively influenceable by opioids. In our opinion it is longtime overdue to strive for an authorization for opioids against breathlessness.
A placebo-controlled trial of aprepitant for cough in lung cancer.
Authors: Harle Amelie Sylvia Mary , Smith Jaclyn A , Molassiotis Alex , Lofthouse Kimberley , Dockry Rachel , Russell Philip , Burns Katy , Blackhall Fiona Helen
Published: February 2017

2

Background: There are no evidence-based therapies for cough in lung cancer (LC).The neurokinin-1 (NK-1) pathway is implicated in cough. Aprepitant is an NK-1 antagonist used as an antiemetic. We assess aprepitant as an antitussive, using objective daytime ambulatory cough monitoring (ACM) as the primary endpoint. Methods: LC patients with a “bothersome” cough were enrolled on an exploratory single-arm randomised double-blind crossover trial and received 125mg aprepitant on day 1 and 80mg on days 2 and 3 or matched placebo capsules. After a 3 day wash out,patients crossed over to placebo or aprepitant for 3 days (days 7-9). They completed ACM and validated subjective cough tools. Results: 20 LC patients were enrolled between 7th Oct 2013-3rd Nov 2014; mean age 66 yrs (SD 7.69); 60% (n=12) female; 70% (n=14) ex, 25% (n=5) current and 5% (n=1) never smokers respectively. 20% (n=4), 55% (n=11) and 25% (n=5) had a performance status of 0, 1 and 2 respectively. The majority (80% n=16) had non-small cell LC; half (n=10) had advanced stage; 20% (n=4) were on anticancer therapy. Daytime cough frequency was 15.9 (95%CI 10.1-28.3 n=19), 12.8 (95% CI 8.7-18.8 n=18) and 16.2 (11.3-23.0 n=19) coughs/hr at baseline, on aprepitant and on placebo respectively: p=0.03. Visual analogue scale scores (range 0-100, high score=worse severity) were 57.0mm (95% CI 47.4-67.2 n=19), 40.8mm, (95%CI 34.3-47.3 n=18), and 49.8mm (95%CI 44.2-55.4 n=19) at baseline, on aprepitant and on placebo respectively: p=0.008. The Manchester Cough in Lung Cancer Scale score (range 1-50, high score = worse cough impact) was 25.2 (95%CI 23.0-28.0 n=19), 19.5 (95%CI 17.8-21.2 n=18) and 21.7 (20.3-23.1 n=18) at baseline, on aprepitant and on placebo respectively: p<0.001.There were no serious adverse events. Conclusions: This is the first trial to assess the efficacy of a novel antitussive using validated subjective and objective cough tools in LC and the first to investigate a centrally acting NK-1 antagonist in humans. Aprepitant treatment was associated with statistically significant improvements in objective and subjective scores. The NK-1 receptors may be key mediators in cough in LC. It is possible to run a robust trial using validated measures with clinically meaningful endpoints in a LC population. Clinical trial information: ISRCTN16200035.
Survival comparison of patients treated with one versus five fraction palliative radiotherapy.
Authors: Dudley Sara , Qian Yushen , Chaudhuri Aadel , Kumar Kiran , Aggarwal Sonya , Chang Daniel Tandel
Published: February 2017

200

Background: Choice of fractionation scheme for palliative radiotherapy has received greater attention in recent years, particularly in the current healthcare environment where issues of cost and quality of life have taken on increasing importance. The ASTRO Choosing Wisely campaign recommends against routine use of extended fractionation schemes ( > 10 fractions) for palliation of bone metastases given equivalent pain relief between 30 Gy in 10 fractions and 8 Gy in 1 fraction, and strong consideration for use of 8 Gy in 1 fraction is urged for patients with a limited prognosis or transportation difficulties. We investigated whether there was a difference in survival between patients treated with an intermediate fractionation scheme (5 fractions) and patients who received single-fraction treatment. Methods: We identified 220 patients who received a total of 264 courses of palliative radiotherapy with either 8 Gy in 1 fraction (n = 91) or 20 Gy in 5 fractions (n = 173). Date of death was obtained from either the patient’s medical record, the Social Security Death Index, or publicly available obituaries. If none of these yielded a date of death, patients were censored at the date of their last clinical encounter. The majority of patients (n = 192) were treated for bone metastases. All primary sites were included, with the three most common histologies being lung, breast and prostate (n = 80, 31 and 16, respectively). Results: Overall, we found no significant survival difference between the two groups. Patients treated with 8 Gy in 1 fraction had a median survival of 146 days, whereas patients treated with 20 Gy in 5 fractions had a median survival of 183 days (p = 0.43). Conclusions: Given no difference in survival between fractionation schemes of 20 Gy in 5 fractions and 8 Gy in 1 fraction, delivery of palliative radiation in a single fraction should be strongly considered. Previous studies have identified a higher re-treatment rate in single-fraction treatments, although closer analysis of this data revealed no difference in absolute pain scores prior to re-treatment. Thus, re-treatment for single-fraction radiotherapy may be due instead to a greater clinical willingness to re-treat as opposed to a greater clinical need.
Netupitant/palonosetron (NEPA) for prevention of delayed chemotherapy-induced nausea and vomiting (CINV) in multiple cycles of chemotherapy.
Authors: Schwartzberg Lee Steven , Gralla Richard J. , Kashef Kimia , Rugo Hope
Published: February 2017

211

Background: Prevention of CINV in the delayed phase (24-120 h post-chemotherapy) and over multiple cycles of chemotherapy remains a challenge. NEPA, a fixed combination of the NK1 receptor antagonist (RA) netupitant (300 mg) and the 5-HT3 RA palonosetron (PALO; 0.5 mg), has demonstrated efficacy in multiple studies, in both acute and delayed phases, during the first cycle of moderately or highly emetogenic chemotherapy (MEC and HEC, respectively) regimens. Two clinical trials evaluated NEPA over multiple cycles of chemotherapy. We report data for the delayed phase for each cycle. Methods: Both studies were Phase 3, double-blind, active-controlled studies. In study 1 (MEC), patients were randomized 1:1 to receive a single oral dose of NEPA (n = 724) or PALO 0.5 mg (n = 725) on Day 1; following cycle 1, patients could participate in a multi-cycle extension phase. In study 2 (MEC or HEC), patients were randomized 3:1 to receive a single oral dose of NEPA on Day 1 (n = 309) or oral aprepitant (APR) 125 mg plus oral PALO 0.5 mg on Day 1, then APR 80 mg/d on days 2 and 3 of each cycle (n = 103). In both studies, all patients also received dexamethasone. Efficacy endpoints included complete response (CR; no emesis, no rescue medication) and no significant nausea. Results: In both studies, CR rates were consistently numerically higher with NEPA (Study 1 range: 77%-89%; Study 2 range: 83%-93%) than with PALO (Study 1; range: 69%-83%) or APR/PALO (Study 2; range: 78%-88%) in each cycle up to cycle 6 (Table). In both studies, rates of no significant nausea in the NEPA group were similar to or higher than in the control group. NEPA was well tolerated in both studies; treatment-related adverse events included constipation and headache. Conclusions: These studies demonstrate sustained efficacy of NEPA (administered as a single dose on Day 1) across multiple cycles of MEC or HEC for prevention of CINV in the delayed phase. Clinical trial information: 2009-016775-30; 2010-023297-39. [Table: see text]
Delirium assessment in patients with advanced cancer presenting to the emergency department of a comprehensive cancer center.
Authors: Elsayem Ahmed F. , Valentine Alan D. , Warneke Carla L. , Page Valda D , Bruera Eduardo , Yeung Sai-ching J. , Brock Patricia A , Silvestre Julio , Holmes Holly Michelle , Todd Knox H
Published: February 2017

217

Background: The exact frequency of delirium among patients with advanced cancer presenting to emergency departments (EDs) is unknown. The purpose of this study is to determine the prevalence of delirium among patients with advanced cancer who present to the ED at MD Anderson Cancer Center. Methods: The exact frequency of delirium among patients with advanced cancer presenting to emergency departments (EDs) is unknown. The purpose of this study is to determine the prevalence of delirium among patients with advanced cancer who present to the ED at MD Anderson Cancer Center. Results: A total of 624 patients were screen for this study, and 243 patients were enrolled. The main reasons for exclusion were: 1) cancer was not advanced, 2) the patient had been in the ED for over 12 hours and 3) the patient was non-English speaking. The median age for all patients enrolled was 62 years (range 19 – 89 years), 167 (69%) were white, and 120(49.4) were female. CAM was positive in 22(9%) of patients. The median MDAS score of CAM positive patients was 14 (range 9 – 22 out of 30). Ten (10%)of 99 patients aged 65 and older were delirious as compared to 12 (8%) of 144 patients younger than 65 years (p = 0.6). Physician correctly predicted delirium in 13 patients (59%). Among the patients who were CAM positive 18 (82%) were admitted to the hospital as compared to 115 (52%) of patients without delirium (p = 0.012). Patients with delirium had higher hospital, and six months mortality rate. Conclusions: Delirium was identified in 9% of patients with advanced cancer visiting an ED, and is associated with more hospitalization and poor survival.
Depression and anxiety among family caregivers of patients with advanced cancer.
Authors: Nipp Ryan David , Fishbein Joel , El-Jawahri Areej , Pirl William F. , Moran Samantha M.C. , McCarty Caitlin , Eusebio Justin , Gallagher Emily R. , Park Elyse R. , Jackson Vicki A. , Greer Joseph A. , Temel Jennifer S.
Published: February 2017

224

Background: Despite the important role family caregivers (CGs) play in the care of patients with cancer, little is known about their psychological distress. We sought to describe rates and correlates of depression and anxiety in CGs of patients with advanced cancer to determine those at greatest risk for psychological distress. Methods: As part of an ongoing trial of early palliative care, we are assessing baseline depression and anxiety in patients within 8 weeks of advanced lung or gastrointestinal cancer diagnosis and their CGs. We are administering the Hospital Anxiety and Depression Scale (HADS), with subscale scores >7 denoting clinically significant depression or anxiety. We are assessing patient coping styles with the Brief COPE. We used multiple logistic regression with purposeful selection of covariates to identify correlates of CG depression and anxiety. Results: Of 240 CGs (mean age=57 years), 156 (65%) were spouses/partners, 167 (70%) were female, and 131 (55%) were working. 37 (15%) and 102 (43%) CGs reported significant depression and anxiety, respectively. CG age, gender and employment status, as well as patients’ anxiety and lack of acceptance coping were associated with higher rates of CG depression. CG age, gender, marital status and education level, as well as patients’ anxiety and presence of brain metastases were associated with higher rates of CG anxiety. Conclusions: Younger, female CGs were at greatest risk of both depression and anxiety. Thus, this CG population should be monitored closely and referred for cancer center support services for distress management. We also found that patients’ anxiety was associated with higher rates of both CG depression and anxiety, underscoring the importance of interventions that address both patient and CG psychological distress. Clinical trial information: NCT01401907. [Table: see text]
Dignity therapy for advanced cancer patients.
Authors: Dose Ann Marie , Hubbard Joleen Marie
Published: February 2017

225

Background: Recent guidelines promote simultaneous palliative care with active treatment for advanced/metastatic cancers, including interventions addressing all quality of life (QOL) domains. Dignity Therapy (DT) is an intervention demonstrating promising outcomes at end of life. It has not been offered earlier to cancer patients nor paired with a Life Plan (LP) intervention. The purpose of this phase I/II feasibility study was to determine the feasibility, acceptability and selected patient-reported outcomes (PROs) of the Dignity Therapy/Life Plan intervention and pilot study methods in advanced pancreatic cancer patients pursuing chemotherapy. Methods: DT is a brief psychotherapeutic intervention consisting a focused life review/values clarification delivered during 3 outpatient oncology clinic visits. Interviews were audiotaped, transcribed, and edited to produce a Generativity Document, which the patient can later share with family. Life Plan is a type of “bucket list”, where patients document future hopes/dreams. Feasibility was evaluated, distress measured with the Distress Thermometer (0-10 scale) and QOL measured with the Linear Analogue Self Assessment (LASA, 0-10 scale). Baseline scores of distress and QOL were compared with scores after the intervention, 4-6 weeks later (Time 2 [T2]). Results: Ten pancreatic adenocarcinoma patients enrolled, mean age 63. Two-thirds of those recruited enrolled; 90% completed all study procedures. Two-thirds were satisfied/very satisfied with DT/LP, and 78% found study participation worthwhile, DT/LP timing to be just right and would recommend DT/LP to others. QOL improved (baseline mean = 7.0; T2 = 7.25). Distress scores improved (Baseline mean = 6.13; T2 = 5.63). Conclusions: Distress and QOL modestly improved from baseline to T2. Baseline scores were collected before patients had begun any chemotherapy, therefore any improvements while undertaking aggressive chemotherapy are noteworthy. Participants felt the intervention was acceptable and better than they had expected. Conducting DT/LP in an outpatient oncology setting for newly diagnosed pancreatic cancer patients is both feasible and acceptable. Outcomes are encouraging for future larger scale trials. Clinical trial information: NCT02132325.
Enhancing the cancer survivors' experience with tailored supportive services.
Authors: Palos Guadalupe R. , Lewis-Patterson Paula A. , Chapman Patricia , Gilmore Katherine Ramsey , Rodriguez Maria Alma
Published: February 2017

236

Background: Maintaining health and well-being is a primary goal throughout the cancer experience. The dynamic nature of a survivor’s trajectory makes it difficult to tailor education and supportive care services to their actual needs. We sought to determine information and education needs preferred by survivors who had returned to their communities after completing their treatment. Methods: We partnered with survivors' advocacy groups to conduct a needs assessment with adult survivors attending a community survivorship conference. Once eligibility was confirmed, verbal consent was obtained, and instructions were given on survey completion. A modified version of the NCI Follow-Up Care Use among Survivors survey was used. Analyses focused on clinical/sociodemographic characteristics, preferences for follow-up care, information/education needs, and sources for receiving health information. Simple descriptives were used to report the results. Results: We distributed 284 questionnaires and 169 were returned, yielding a 59.5% response rate. Respondents were mostly female (79.9%), married (58.6%), college educated (81.7%) and had ver 10 post-treatment years (47.3%). 51.3% were diagnosed with breast cancer and 81.8% reported being in good to excellent health. 57.3% had follow-up cancer care, 30.8% did not recall having a discussion with their provider about late-effects, and 57.6% reported not receiving a summary care plan. 83.7% preferred to have the same provider follow them and 95.2% reported their oncologist would be their ideal doctor. Survivors preferred more information on ways to improve memory/concentration (83.9%), energy/exercise (83.3%), and maximizing the benefits of their survivorship care plan (74.6%). Preferred information sources were health care providers (78.0%) and the internet (39.3%). Conclusions: These survivors reported a high level of unmet information needs related to self-management of physical symptoms. Patient-provider communication about late-effects and benefits of survivorship care plans continues to be inadequate. Physicians and other providers are in ideal positions to initiate conversations about supportive survivorship care early in the patient experience.
Integrated Mindfulness-Oriented Recovery Enhancement (MORE) and physical health intervention for cancer survivors with obesity: Preliminary results from a pilot randomized controlled trial.
Authors: Beck Anna Catherine , Garland Eric L. , Hansen Pamela A , Walker Darren , Reimers Celestial , Thomas Elizabeth Ann , Mijangos Jennifer , White Shelley
Published: February 2017

237

Background: Hypothetically, interventions that reduce excessive weight and promote nutrition and physical activity may protect against cancer recurrence. Yet, obesity is often fueled by compulsive eating behaviors. Integrative therapies that combine exercise and nutrition training with techniques to enhance interoceptive awareness and cognitive control over automatic, compulsive eating may be especially efficacious. This pilot study tested the preliminary efficacy of an integrated exercise, nutrition, and Mindfulness-Oriented Recovery Enhancement (MORE) intervention in a sample of obese cancer patient. Methods: Obese (Mean BMI = 35.8) female patients (Mean age 58.41) with breast (n = 15), colon (n = 1), and endometrial cancers (n = 1) were recruited and randomly assigned to receive exercise and nutrition intervention without (POWER, n = 10) or with an additional mindfulness component (MORE POWER, n = 7). Participants met twice weekly for 10 weeks for group exercise and nutrition sessions. MORE POWER participants also participated in 10 weekly group mindfulness sessions. Pre- and post-intervention, assessments included self-report measures, weight and BMI measurement, and a cue-elicited heart rate variability (HRV) assessment. Results: The MORE POWER group evidenced significantly greater reductions in BMI (p = .015) and weight (p = .034; 6.57 lbs. vs. 1.35 lbs.) than the POWER group. The MORE POWER group also reported significantly greater increases in interoceptive awareness (p = .019) and mindful observation than the POWER group (p = .040). Increases in mindful observation predicted residualized change in BMI, Beta = -.13, SE = .05, p = .03. Lastly, MORE POWER group exhibited significantly greater post-intervention HRV than the POWER group (p = .011). Conclusions: Integrating MORE with an exercise and nutrition training program appeared to enhance weight loss outcomes in this pilot sample of obese cancer patients. Findings suggest that mindfulness training may strengthen cognitive regulation of appetitive and motivational reactions crucial to weight loss, and thereby promote health in cancer survivors.
Resiliency among nursing staff in an inpatient medical oncology unit.
Authors: Carr Alaina L , Traeger Lara , Cashavelly Barbara J. , Pirl William F.
Published: February 2017

24

Background: Inpatient medical oncology nursing staff members often care for seriously ill patients with complex needs, and are at particular risk for burn out. This qualitative study explored the experiences of registered nurses (RN) and nurse practitioners (NP) on an inpatient medical oncology unit. We identified factors influencing resiliency in caring for oncology inpatients on a daily basis. Methods: We conducted in-depth qualitative interviews with 24 RNs and 13 NPs working on an inpatient medical oncology unit at an academic medical center. A semi-structured interview guide was used to elicit perspectives on facilitators and barriers to resilience in caring for oncology patients. Content analysis was conducted to identify themes between RNs and NPs. Results: Both RNs and NPs described being emotionally affected by daily experiences with patient suffering and death. However, they commonly identified that relationships with patients at the end of life (EOL) were sources of profound inspiration; and they felt privileged to engage with patients during this significant phase of their lives. Factors that negatively impacted resilience included a) barriers to communicating with team members and patients about EOL issues, b) successions of acutely ill patients on the unit, and c) work-life balance issues in the context of intensive shift schedules. Following emotionally difficult days, staff found motivation to return to work the next day through: a) mutual understanding and support from unit coworkers, b) sense of connection to seriously ill patients and their families, and c) general perception of oncology nursing as part of one’s identity. Conclusions: Nursing staff were intrinsically motivated to connect with seriously ill patients and to provide meaningful EOL care. Connections with coworkers and patients/families and personal identification with the role of oncology nursing helped staff to return to work after emotionally difficult experiences on the unit. Results identify potential targets for intervention to increase resiliency, including increasing workplace cohesion, communication and support within the unique inpatient milieu.