bluuebunny/crossref_metadata_2025 huggingface dataset:
Rates of unacceptable variation (UV) of normal tissue constraints in patients undergoing chest wall/breast and regional nodal irradiation (RNI) in a routine clinical practice.
Authors: Bazan Jose , DiCostanzo Dominic , Majithia Lonika , Quick Allison Marie , Gupta Nilendu , White Julia R.
Published: February 2017

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Background: TheNSABP B51/RTOG 1304 clinical trial defines dose-volume constraints for targets/normal tissue receiving RNI. We sought to evaluate UV rate in normal tissue based on the NSABP B51/RTOG 1304 protocol in patients receiving chestwall/breast (CW/B) and RNI in daily practice. Methods: Treatment records of CW/B+RNI patients from 2/2012-5/2015 were studied for: CW or B radiotherapy (RT), RT type (intensity modulated [IMRT] or 3D conformal [3DCRT]), internal mammary node (IMN) inclusion, primary site boost, and nodal boost. No case is enrolled on B51/1304. Dose volume histogram (DVH) was analyzed for the rate of ≥ 1 UV for the following normal tissue constraints: Heart mean dose ≤ 5 Gy; ipsilateral lung (IL): V20 ≤ 35%, V10 ≤ 60%, V5 ≤ 70%; contralateral lung (CL) V5 ≤ 15%; contralateral breast (CB) V4.1 ≤ 5%. Logistic regression is used to test the association between UV and key variables. Results: 203 consecutive cases received CW/B+RNI (105 left, 98 right). RT was to CW in 170 (84%), B in 33 (16%), primary site boost 133 (66%), and IMN 170 (84%). 38 (19%) received IMRT and 14 (6.9%) had a nodal boost. 46 patients (22.6%) had ≥ 1 UV. 19 patients (9.4%) had ≥ 2 UV, all in IMRT patients. 2 patients (1.0%) had a heart UV at 5.2 Gy and 5.6 Gy. The most common UV was CB (n = 32, 15.7%) and IL V5 (n = 22, 10.8%). Higher UV rates are associated with use of IMRT (vs. 3DCRT): 86.8% vs. 7.9%, OR = 77.2 (95% CI 25.7-231.4, p < 0.0001); IMN irradiation: OR = 11.5 (95% CI 1.5-86.8, p = 0.02); and use of nodal boost: OR = 7.4 (95% CI 2.3-23.4, p = 0.001). The most common UVs in IMRT cases are CB (n = 27, 71%), IL V5 (n = 19, 50%), CL V5 (n = 14, 37%) and for 3DCRT are IL V20 (n = 5, 3%), CB (n = 5, 3%) and IL V5 (n = 3, 1.8%). On multivariate analysis, use of IMRT (OR = 64.7, 95% CI 20.8-201.5, p < 0.001) and use of nodal boost (OR = 5.5, 95% CI 1.1-27.1, p = 0.04) but not IMN irradiation (OR = 2.7, 95% CI 0.3-22.0, p = 0.35) were independently associated with higher UV rate. Conclusions: The rate of UV per B51/1304 criteria with 3DCRT in routine clinical practice is low (7.9%). Women treated with IMRT had a significantly higher overall UV rate and clinicians should be aware of this as they initiate treatment planning for RNI.
Phase III study of APF530 versus ondansetron with a neurokinin 1 antagonist + corticosteroid in preventing highly emetogenic chemotherapy-induced nausea and vomiting: MAGIC trial.
Authors: Schnadig Ian D. , Agajanian Richy , Dakhil Shaker R. , Gabrail Nashat Y. , Smith Robert E. , Taylor Charles W. , Wilks Sharon , Cooper William , Mosier Michael , Payne Yvette , Klepper Michael , Vacirca Jeffrey L.
Published: February 2017

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Background: Managing chemotherapy-induced nausea and vomiting (CINV) associated with delayed ( > 24-120 h) highly emetogenic chemotherapy (HEC) is an unmet need. APF530, extended-release granisetron, provides sustained release over ≥ 5 days to prevent acute (0-24 h) and delayed CINV. This trial compared the efficacy and safety of APF530 in preventing CINV after HEC in a 3-drug regimen vs a standard 3-drug regimen with ondansetron (Ond). Methods: In this double-blind, multicenter study (NCT02106494), patients (pts) receiving single-day HEC (2011 ASCO guidelines) were randomized 1:1 to APF530 500 mg SC (10 mg granisetron) or Ond 0.15 mg/kg IV and stratified by cisplatin ( ≥ 50 mg/m2, yes/no). Pts were scheduled to receive concomitant dexamethasone (Dex) 12 mg IV + fosaprepitant (Fos) 150 mg IV on day 1 + PO Dex on days 2-4. The primary end point was delayed-phase complete response (CR) (no emesis, no rescue medication). Secondary end points included CR in acute and overall phases and complete control (CC; CR and no more than mild nausea) in acute, delayed, and overall phases. Treatment (tx) comparisons used chi-square test controlling for cisplatin. Adverse events (AEs) and injection-site reactions (ISRs) were assessed. Results: Modified intent-to-treat analysis included 902 pts (APF530, n = 450; Ond, n = 452) with baseline demographics balanced between tx groups. A significantly higher % of APF530 (65%) vs Ond (57%) pts had delayed-phase CR (P= .014). A significantly higher % of APF530 (61%) vs Ond (53%) pts had delayed-phase CC (P= .022, Table). CR and CC rates in acute and overall phases were numerically higher with APF530 vs Ond, but not statistically significant. APF530 was well tolerated. Most common AEs were ISRs, mostly mild or moderate. Conclusions: APF530 with Fos+Dex led to statistically higher CR and CC rates in delayed-phase CINV with HEC vs a standard 3-drug regimen of Ond with Fos+Dex. Clinical trial information: NCT02106494. [Table: see text]
Clinical utility of the radiation dose management system for full field digital mammography (FFDM): In Asian women with dense breast tissue.
Authors: Kang Bong Joo , Baek Ji Eun , Lee Hyun Sil , Kim Sung Hun
Published: February 2017

70

Background: In the perspectives on radiation dose, there are consensus of importance on radiation dose management for patient safety and trends to reduce radiation dose for patient safety. Radiation dose management system like Radimetrics helps radiologists optimize protocols and reduce radiation dose. There is no previous data applying the radiation dose management system in mammography.We investigated the clinical usefulness of the radiation dose management system in full field digital mammography (FFDM) using commercial Radiation dose management system. Methods: We did radiation dose tracking, monitoring, and statistics through the existed radiation dose management system (Radimetrics). The utilization data, parameter, and dose report were sent to the conventional picture archiving and communication system (PACS) and the Radimetrics enterprise flat form. And we could review the data including age, kVp, mAs, breast thickness, and compression force under the web base. We analyzed the breast composition depending on the BI-RADS assessment categories. We evaluated the correlation of the age, kVp, mAs, breast thickness, compression force, and breast composition with organ dose of breast. Additionally, in patients with above diagnostic reference level ( ≥ 75%) of radiation dose, the causes were analyzed. Results: From February to May 2015, 3076 sets of FFDM were performed and sent to PACS and the radiation dose management system (Radimetrics). In total 3076 sets, 2520 were routine bilateral FFDM with 4 views. The mean glandular dose was 6.59± 2.87 mGy (2.63-18.46). In the correlation analysis, the age had moderate negative linear relationship with organ dose. The mAs and breast composition had moderate positive linear relationship with organ dose. The kVp, breast thickness, and compression force had weak positive linear relationship with organ dose. Patients with above diagnostic reference level ( ≥ 75%) of radiation dose showed dense breast composition and thicker breast. Conclusions: The radiation dose management system is useful in FFDM. Especially in Asian women with thick and dense breasts, radiation dose should be carefully managed.
Unnecessary axillary lymph node dissection in the era of sentinel lymph node biopsy.
Authors: Yen Tina W.F. , Laud Purushottam W. , Pezzin Liliana E , McGinley Emily , Wozniak Erica , Sparapani Rodney A. , Nattinger Ann B
Published: February 2017

71

Background: No population-based effectiveness studies have been performed to determine to what extent breast cancer patients are benefiting from sentinel lymph node biopsy (SLNB). This study investigates the extent of unnecessary axillary lymph node dissection (ALND) by surgeon volume and specialty, and estimates the resultant rates of excess lymphedema (LE). Methods: Women with Stage I-III pathologically node-negative (pN0) breast cancer diagnosed in 2008-2009 were identified from the SEER-Medicare linked database. Patients who received neoadjuvant chemotherapy were excluded. Type of axillary surgery was defined by claims. Unnecessary ALND was defined as a patient who underwent either an initial ALND or SLNB followed by ALND. Surgeon volume tertiles were created with roughly a third of cases in each volume group (low, medium, high). Surgical specialty (surgical oncologist, general, other) was determined by the specialty code listed on the claim. A logistic regression model, adjusting for patient and tumor characteristics, was performed to predict the likelihood of receiving an unnecessary ALND. Estimates of LE rates were determined based on the number of nodes removed. Results: 7,946 pN0 patients underwent surgery by 2,101 surgeons. Half underwent SLNB only; 50% had unnecessary ALND (39% converted from SLNB to ALND, 11% ALND only). There was an interaction between surgeon volume and specialty (p < 0.01); surgical oncologists, compared to non-surgical oncologists, were less likely to perform unnecessary ALND in all three volume groups. This effect was largest in the medium volume group (OR 0.37; 95% CI: 0.26-0.51). The LE probability was 14% with an excess LE rate of 4.5%. Unnecessary ALNDs accounted for 84% of the estimated excess LE patients and represented 27% of all potentially avoidable LE cases. Conclusions: Half of pN0 patients underwent unnecessary ALNDs, which accounts for 27% of all potentially avoidable LE cases. The likelihood of undergoing an unnecessary ALND was lower in all three surgeon volume groups if patients were operated on by surgical oncologists. Policies to assess surgeon proficiency in SLNB and/or regionalization of care should be considered to decrease rates of unnecessary ALND and ultimately LE.
Treatment costs of breast cancer among younger women aged 19 to 44 years enrolled in Medicaid.
Authors: Ekwueme Donatus U. , Allaire Benjamin T. , Guy Gery , Arnold Sarah , Trogdon Justin G
Published: February 2017

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Background: Breast cancer is the most common malignant tumor among women in the United States, accounting for about 30% of incident cancers. It is one of the most costly medical conditions to treat. Younger women aged 18-44 years account for 11% of new cases. These women tend to experience more aggressive types of breast cancer, requiring intensive and expensive treatment. In recent years, a few studies have examined the costs of breast cancer treatment in a Medicaid population at the state level. However, no study has estimated medical costs for breast cancer treatment at the national level for women aged 19-44 years enrolled in Medicaid. Methods: A sample of 5,542 younger women aged 19-44 years, fee-for-service Medicaid enrollees, and diagnosed with breast cancer in 2007 were compared with 4.3 million women aged 19-44 years, fee-for-service Medicaid enrollees, but without breast cancer. The study used linear and nonlinear regression methods to estimate treatment costs for younger women with breast cancer compared with those without breast cancer. Individual medical costs were estimated by race/ethnicity and by type of services. All medical treatment costs were adjusted to 2010 dollars. Results: The estimated annual direct medical costs for breast cancer treatment among younger women enrolled in Medicaid ranged from nearly $25,000 to $42,000 per woman. Non-Hispanic black women had the highest annual total medical costs, followed by Hispanic women, while non-Hispanic women of other race had the lowest. The cost estimates ranged from $14,600 to $18,800 for outpatient service, $4,600 to $5,700 for inpatient service, and $3,500 to $4,800 for prescription drugs. Conclusions: The cost estimates demonstrate the substantial medical costs associated with breast cancer treatment for younger Medicaid beneficiaries. As the Medicaid program continues to evolve, the treatment cost estimates could serve as important inputs in decision-making regarding planning for treatment of invasive breast cancer in this population.
Impact of dosing schedule of doxorubicin and cyclophosphamide (AC) chemotherapy on rates of hospitalization and resource utilization.
Authors: O Donovan Helen , Murphy Kate , Bird Brian Richard , Murphy Conleth G.
Published: February 2017

78

Background: 4 cycles ofAC chemotherapy are given as a component of several important and widely used chemotherapy regimens in the adjuvant treatment of breast cancer. We queried whether the use of dose-dense (every 2 week) AC chemotherapy is associated with a lower rate of hospitalization and resource utilization in clinical practice. Methods: We identified patients with early stage breast cancer treated with 3-weekly AC chemotherapy in a single institution. Cases were matched to controls by year of diagnosis and age. Rates of hospitalization during AC chemotherapy as well as duration of hospitalization, associated costs and use of pegfilgrastim were compared between the two groups. Fisher's exact test was used to compare categorical variables, and paired t-test was used to compare continuous variables. Results: 26 patients were included in the analysis. The mean age was 56 in both groups. As expected, rates of growth factor support with pegfilgrastim were higher in the dose dense versus 3-weekly group (52 versus 23 cycles, 2-tailed p = 0.0003). There was no difference in the likelihood of hospitalization among patients treated with dose dense versus 3-weekly AC (Fisher's exact test, p-value = 1.00). There was no difference in the mean duration of hospitalization between groups (mean 2.31 versus 1.23 days, 2-tailed p = 0.3352).Costs pertaining to pegfilgrastim use and hospitalization will be compared. Conclusions: In this clinical setting, dose dense administration of AC was not associated with lower rates or mean duration of hospitalization.
Patient-reported distress screening outcomes in breast cancer.
Authors: Smart Bridget , Vallow Laura , Hollant Laeticia , Single Megan , Gaines Katherine , Habboush Jacob , Biers Heather , Day Atiya , Tzou Katherine S. , Miller Robert Clell
Published: February 2017

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Background: A significant percentage of cancer patients experience psychosocial distress with the highest prevalence observed in breast cancer patients. The importance of psychosocial distress screening and assessment in women with breast cancer has clearly been established. Patients in our clinic are screened for distress. The results were reviewed in an attempt to better understand the psychosocial distress of breast cancer patients undergoing radiotherapy. Methods: Patients treated curatively for breast cancer prospectively completed the 30 question patient reported distress (PRD) survey that also included a linear analog measure of overall distress. The recorded clinical results of the PRD survey were retrospectively assessed in patients receiving breast radiotherapy from June 1, 2013 to February 2, 2015. Results: Completed PRD questionnaires were available on 179 female patients. 21 (12%) were treated for ductal carcinoma in situ and 91 (51%), 35 (20%), and 32 (18%) were treated for invasive carcinoma Stages I, II, and III. 85 (47%) received chemotherapy. Overall distress ranged from 0 to 10, with a median value of 5. Mean distress scores per category ranged from a low of 1.25 to a high of 2.52. Top concerns in descending order of importance were: “How will I feel during treatment” (2.52), “Fatigue” (2.46), “Sleep difficulties” (2.32), “How will I feel about appearance related to treatment” (2.23), & “Pain that affects daily functioning” (2.19). Least distressing symptoms “Spirituality” (1.25), “Housing during treatment” (1.26), “Control of anger” (1.28), “End of life concerns” (1.32), & “Transportation” (1.34). Conclusions: Distress over tumor related issues ranked low among women’s concerns in comparison to distress related to the side effects of therapy concerning treatment related discomfort, fatigue, and changes in appearance, and anxiety. Pain was a significant concern, although in this group of patients receiving definitive, adjuvant or neoadjuvant therapy, this was likely related to treatment associated discomfort rather than from disease progression. These findings highlight the importance of careful patient education and communication of the expected symptoms and effects of therapy.
The prevalence and pattern of chemotherapy-induced peripheral neuropathy (CIPN) among women with breast cancer receiving care in a large community oncology practice.
Authors: Simon Natalie Brooke , Danso Michael A. , Alberico Thomas , Basch Ethan M. , Bennett Antonia Vickery
Published: February 2017

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Background: CIPN is a common side effect of taxane-based chemotherapy agents. This study examined the prevalence, severity, and risk factors of CIPN and its impact on quality of life (QOL) among women treated for breast cancer in a large U.S. community oncology practice. Methods: In this cross-sectional survey study, women previously treated with taxane-based chemotherapy for early stage breast cancer completed the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30), breast cancer module (QLQ-BR23) and CIPN module (QLQ-CIPN20). Each subscale is scored 0-100 where higher scores indicate better function or greater symptom severity. Clinical data were abstracted from the medical record. Bivariate analyses were conducted to test pre- specified hypotheses. Results: 126 women with mean age 56.7 years (SD = 11.8) were stage I-II (79.4%) or stage III (20.6%) at the time of the survey; 65.1% were White and 27.8% were Black or African American. 73.0% of women reported they had CIPN. The mean time since last taxane chemotherapy cycle was 144.9 weeks (SD = 112.9). The mean (SD) score of QLQ-C30 global health status/QOL was 77.0 (20.3) and physical function was 85.7 (17.1). QLQ-CIPN20 mean scores for the sensory, motor, and autonomic subscales were 18.9 (23.1), 18.6 (18.7), and 17.1 (21.8), respectively. Presence of CIPN was associated with patient referral and visitation to a neurologist or pain specialist (p < 0.05). CIPN symptom severity was negatively correlated with global health status/QOL and physical and role functioning (range of r= -0.46 to -0.72). Further, it was not associated with age, body mass index, diabetes, or cumulative taxane dosage, but was greater for Black or African American patients versus White patients (e.g., sensory: 28.6 vs 14.5, p < 0.002). CIPN sensory impairment was marginally greater for patients treated with paclitaxel compared to docetaxel (23.3 vs 15.6, p < 0.06). Conclusions: CIPN was prevalent in this community oncology practice and significantly impacts function and QOL. These data highlight the importance of developing methods to mitigate CIPN.
Comparison of prognosis and specific features according to tumor size in small-sized breast cancer with extensive lymph node involvement.
Authors: Han Hong-Seok , Paik Hyun-June , Ryu Jai Min , Park Sungmin , Yi Ha Woo , Bae Suyeon , Lee Sekyung , Kil Won Ho , Lee Jeong Eon , Nam Seok Jin , Kim Seok Won
Published: February 2017

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Background: As known, larger tumor size and more extensive lymph node (LN) involvement have been considered an independent factor for poor prognosis of breast cancer. We evaluated if very small tumor size may be a factor of worse prognosis compared to larger tumor in small sized breast cancer with LN involvement. Methods: A retrospective analysis was made in a single center of all 1400 patients with small (below 2cm, T1) sized and LN involved (N1~N3) breast cancer without metastasis diagnosed between 2004 and 2014. Their ages ranged from 23 to 88 years (mean age 49.1 ± 9.9 years) and mean follow-up was 31 months. All patients were performed with surgery including axillary LN dissection without neo-adjuvant chemotherapy. We subdivided their tumor size to 4 group (T1m, T1a, T1b and T1c) grading by 7th AJCC cancer staging. The number of patients in each group is as follows: T1m = 17, T1a = 63, T1b = 214, T1c = 1106. The specific features related to mortality were analyzed according to the minor groups and they were compared with one another by Chi-square test and Kaplan-Meier analysis. Results: Total expired patients were 39 (2.8%) and the number (the rate in each group) of the minor groups is as follows: T1m = 1 (5.9%), T1a = 1 (1.6%), T1b = 7 (3.3%), T1c = 22 (2.0%). Overall survival of smaller sized tumor groups ( ≤ 1cm, T1m+T1a+T1b) are significantly decreased than the other larger sized group T1c in T1N1 staged patients (p = 0.004). There are significant differences in estrogen receptor, progesterone receptor, nuclear grade, recurrence among the 4 minor groups in whole patients group. In the analysis of nuclear grade, the results show higher grade in T1m than T1a, T1m than T1b, T1b than T1c. Especially, recurrence of T1m is significantly more frequent than T1a (17.6% vs 3.2%, P = 0.03) or T1b (17.6% vs 4.2%, p = 0.016). Conclusions: In conclusion, this study indicates smaller sized tumor with LN involvement can progress worse compared to larger tumor. This result supports very small size can be another predictive factor for prognosis in small sized breast cancer with LN involvement.
Voice of Cancer Patients: Analysis of patient concerns regarding cognitive deficits associated with treatment for breast cancer.
Authors: Aggarwal Sangeeta , Liu Mingfeng , Sharma Rishi , Yang Fred , Gupta Ankit , Singh Divjot , Sharma Rahul , Basak Anirban , Aggarwal Alok
Published: February 2017

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Background: Patients undergoing breast cancer treatment often report Symptoms of Cognitive Deficit (SCD). Many of them share their experiences on online forums, which contain millions of freely shared messages that can be used to analyze these SCD. Unfortunately, this data is unstructured, making it difficult to analyze. In this project we organize this data using methods from Big Data Science (BDS) and analyze it by creating a Decision Support System (DSS): an interface that can be used by patients and providers to understand how SCD are associated with specific types – hormonal only (HT), chemo only (CT), or both (CT/HT) – of breast cancer therapies. Methods: We collected 3.5 million unique messages from 20 unrestricted breast cancer forums that provide clinically relevant information. We next built custom ontologies for breast cancer treatments, SCD, and supportive therapies. Then, we created a DSS using methods from BDS, including topic modeling, information retrieval, and natural language processing to extract the relevant data from these messages. We also used token windows and co-occurrence-based algorithms to associate treatment with SCD and supportive therapies. To use this system, a user provides disease-related parameters and the treatment. The DSS then gives the percentage of messages discussing SCD for a similar cohort of patients and the percentage of messages that discuss supportive therapies for each of these SCD. Results: We found 15719 messages that had strong association of SCD with treatments. 3355 messages were from HT patients, 5740 messages were from CT patients, and 9095 messages were from CT/HT patients. Among HT, 28.18% patients taking aromatase inhibitors and 19.20% taking tamoxifen associated SCD to HT. Among CT, 35.26% patient receiving taxane containing chemo associated SCD to CT. SCD worsened during HT for CT/HT patients. Suggestive therapy: 80 messages found Vitamin B12 and B6 useful, 65 suggested Acetyle-L-Carnitine, and 50 suggested playing word games. Conclusions: Using methods from BDS, our DSS reliably associates SCD with HT, CT and CT/CT, and suggests supportive therapies. More research is needed to evaluate the role of supportive therapy for SCD.
Bio-identical hormones replacement therapy and the quality of life for breast cancer patients.
Authors: Wiley TS
Published: February 2017

87

Background: Many treatments for breast cancer block the estrogen receptor or the androgen conversion of estrogen to reduce the risk of relapse. This results in a change in the hormonal milieu. Although most women tolerate the change in hormonal status, problems can arise from this change. Without estrogen, clinical symptoms include hot flashes, sleeplessness, insulin sensitivity, and mood changes. Here, it is examined that the use of estrogen and progesterone bio-identical hormone replacement therapy (BHRT) for women in the normal physiological pattern of reproductive women is expected to coincide with increased well-being and better quality of life for women with breast cancer. Methods: This BHRT approach uses bio-identical estrogen and progesterone to restore the woman’s body to normal serum levels through twice daily transdermal application. Using real “bio-identical” or plant-derived human molecular hormones compounded via a standard formula, concentration, and packaging of transdermal creams (Estradiol E2) of 1 mg/0.1ml and progesterone P4 of 20 mg/0.1 ml). Furthermore, through an understanding of hormonal mechanisms, this BHRT mimics the female reproductive cycle by following a 28 day cycle. Results: Throughout the study, women were asked to how gauge their general well-being and quality of life. Most women reported resolution of menopausal symptoms, better sleep, decreased migraines and incontinence, increased focus, and increased libido. Most patients were pleased to be on the treatment and showed general improvement in the quality of life. Conclusions: We present the general mechanisms of action for BHRT and explain clinical trials conducted over the past decade have been examining the impact on the overall well-being and quality of life for 112 patients, as well as the impact on various cancers as well as other chronic conditions. Patients reported increased energy and overall well-being. BHRT provided resolution of most all of the patients subjective anti-estrogenic complaints. It is also observed that the recurrence rate of various breast cancers was no higher than national averages. Therefore, BHRT and rhythmic dosing seems to greatly improve well-being with no increase of cancer risk.
Emotional experiences of oncologists treating women with metastatic breast cancer (MBC).
Authors: Brufsky Adam , Mayer Musa , Bell Dickson Robyn , Citron Marc L.
Published: February 2017

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Background: Research on the psychological status of medical oncologists (MO) is limited. The Make Your Dialogue Count survey explored emotional experiences of licensed US MOs who treat ≥ 5 women with MBC/month as well as women ( ≥ 21 y) with MBC. Methods: A survey was conducted (June-Aug 2014) online, by paper and telephone; MOs responded online only. Patient (pt) data were unweighted. MO data were weighted by geographic region and years in practice by sex to match actual proportions in the population. Statistically significant differences between groups were determined by standard t-test of column proportions and means at the 95% confidence level (marked by *). Results: 359 pts (median age 53 y) and 252 MOs (median age 49 y; median 15 y in practice) completed surveys. At initial MBC diagnosis, more MOs than pts felt that showing care and compassion (81% vs 72%) and helping pts cope with the diagnosis (63% vs 51%) were very important, and fewer felt that referring pts to support services (24% vs 38%) was very important. More MOs practicing < 15 y vs ≥ 15 y said it was very important to refer pts to support services at first diagnosis (30% vs 19%*). Slightly more MOs with more experience perceived emotions like anxiety, commitment, hopefulness, and determination in their pts at initial diagnosis. Many MOs (42%) reported that treating women with MBC had a lot/a great deal of negative emotional impact; 81% strongly/somewhat agreed that it is unprofessional to let emotions impact treatment recommendations; and 23% reported that emotions kept them from providing some information to pts. Less experienced MOs said their emotions kept them from providing some information to their pts than their more experienced counterparts (29% vs 17%*). Most MOs (93%) did not want to give their pts false hope; yet 27% reported that in certain situations, they do not discuss with pts that MBC is incurable. Conclusions: MOs empathize with pts and feel responsible for providing them emotional/psychological support. MOs revealed the negative emotional weight of their work. MOs with less experience were more impacted by their emotions than MOs with more experience. Acknowledging MOs’ emotions is important and underscores their own need for psychological/emotional support.
Association between daytime activity, sleep, and symptom burden in patients with advanced cancer: A preliminary report.
Authors: Yennu Sriram , Tayjasanant Supakarn , Balachandran Dave , Padhye Nikhil S , Williams Janet L. , Liu Diane D , Bruera Eduardo
Published: February 2017

101

Background: There is limited research in advanced cancer patients (ACP) regarding association between objective daytime activity, sleep variables and symptom burden. Our primary aim was to determine the association between mean daytime activity (MDTA) and objective sleep variables, cancer related fatigue (FACIT-F), symptom burden (ESAS), Anxiety and Depression (HADS), Sleep Quality (PSQI) and overall survival (OS). Methods: Secondary analysis of a recent clinical trial of cancer related fatigue in advanced cancer (NCT00424099). Association between MDTA and sleep variables (measured by actigraphy) during the first week of the study and patient characteristics, symptoms (FACIT-F, ESAS, HADS, and PSQI) and OS were analyzed using Spearman correlation, multivariate analysis and survival analysis. Results: 79 eligible patients were evaluable. The median age was 57 years. Median MDTA was 248.43 counts/min. MDTA was significantly associated with (r, p-value) age (-.379, ≤ .001), serum albumin (.328, .006), FACT-Functional well-being (FWB) (.248, .028), ESAS dyspnea (-.300, .008), HADS-Anxiety (.262, P = .019) and total sleep time (-.323, .004). MDTA was not associated with FACIT-F subscale (p = .997) and OS (p = .18). PSQI was significantly associated with FACIT-F, HADS, ESAS anxiety and depression, but none of these variables were associated with sleep measured by actigraphy. Conclusions: In ACP, lower MDTA was not correlated with patient reported fatigue, and sleep measured by actigraphy was not associated with patient reported sleep disturbance. Both fatigue and sleep disturbance were strongly associated with depression and anxiety. More research is needed to characterize the association between objective and patient reported daytime activity, fatigue and sleep. Clinical trial information: NCT00424099.
A palliative radiation oncology consult service’s impact on care of advanced cancer patients with symptomatic bone metastases.
Authors: Chang Sanders , Smith Cardinale B. , Morrison R. Sean , Rosenzweig Kenneth , Dharmarajan Kavita Vyas
Published: February 2017

110

Background: Single-fraction and ≤ 5 fraction radiation treatment (SF-RT and Hypo-RT, respectively) is underutilized despite strong evidence regarding its efficacy in symptom management. Established in 2013, the Palliative Radiation Oncology Consult Service (PROC) is a specialty service designed to provide individualized, efficient treatment for advanced cancer patients by a radiation oncology team with a dedicated palliative care focus. We assessed the impact of this new model of care on use of SF-RT, hypo-RT, pain improvement, palliative care utilization, and hospitalization among patients treated with palliative radiation (PRT) for painful bone metastases. Methods: We searched electronic charts of advanced cancer patients who had PRT for symptomatic bone mets from Dec 2010 to April 2015, extracting PRT details, demographics, cancer type, pain pre- and 1 month post-PRT, comorbidities (summarized using Charlson comorbidity index [CCI]), palliative care consults, and hospitalization. Comparisons were made before and after PROC using chi-square or t-tests. Multivariable logistic regression estimated the likelihood of SF-RT or hypo-RT, controlling for age, gender, cancer type, treatment site, and CCI. Results: We identified 334 patients, described in the table below. Patients were more likely to have SF-RT (OR 2.2, 95% CI [1.2-3.8], p = 0.007), or hypo-RT (OR 3.0, 95% CI [1.8-4.7], p < 0.001) after establishment of PROC. Conclusions: Establishment of a PROC service nearly doubled utilization of SF-RT and hypo-RT while maintaining pain improvement, and was associated with an increased use of palliative care consult services, decreased inpatient PRT use, and decreased length of stay. A dedicated service combining palliative care principles and radiation oncology improved quality of palliative cancer care. [Table: see text]
Oncologists' attitudes towards patient and family-centered care.
Authors: Nguyen Timothy K. , Bauman Glenn , Watling Christoper J , Hahn Karin
Published: February 2017

111

Background: Patient and family-centered care (PFCC) represents an evolution from traditional models of provider-focused and patient-focused care that places a strong emphasis on optimal patient communication, patient autonomy, and shared decision-making within care teams. A shift towards PFCC requires participation across all provider groups. Despite the importance of physician buy-in, research examining physicians’ perspectives on PFCC is lacking. We sought to explore oncologists’ familiarity with the principles of PFCC and perceived barriers to implementing principles of PFCC. Methods: In this qualitative exploratory study, we conducted semi-structured interviews with 18 oncologists (8 radiation, 4 medical, 4 surgical, 2 hematologist-oncologists) at a single Canadian academic cancer institution. Interview data were analyzed using coding principles drawn from grounded theory. Constant comparisons were used to identify recurring themes. Results: We identified 3 dominant themes related to physicians’ interpretations of PFCC: 1) Physicians expressed a limited understanding of the formal principles of PFCC, 2) Physicians identified patient autonomy as essential to PFCC and 3) Disparities between patient and physician objectives exist and result in compromises that may affect the quality of PFCC delivered. Oncologists perceived that spending more time with patients improved PFCC, but also recognized that it would leave less time for other necessary activities. Participants also identified a number of ‘system’ barriers to PFCC, including limited staff and clinical space, excessive case load, a lack of physician support and input into operational decisions, and funding constraints. Many felt that PFCC was challenged by inefficiencies in the system of care delivery, and that progress might lie in reorganization to more clearly match health care staff’s roles and responsibilities to their credentials and skills. Conclusions: Advancing PFCC in our institution will require continued education of physicians regarding the principles of PFCC, acknowledgement and preservation of the PFCC behaviors already in practice and creative solutions to address the system issues that may hamper their abilities to enact PFCC.
A physician's practice, attitude and approach for the management of palliative care for cancer.
Authors: Feng Shijian , Zhang Qiongwen , Yu Chunhua , Shi Huashan , Yao Wenxiu , Zhao Yuwei , Wang Yongsheng
Published: February 2017

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Background: Pain is the most frequent and persistent symptom experienced by cancer patients. Thus, exploring how to achieve the best outcome of cancer pain management in China is clearly extremely important. Our study focuses on the Chinese physicians' current clinical practice, attitudes, toward and barriers to opioid use, and knowledge of cancer pain management. Methods: A face to face survey include 23 items was designed and conducted to the doctors working with cancer pain managements (oncologists, internists, hematologists, et al) responsible for the care of patients with cancer in 11 tertiary hospitals in China. Descriptive statistics were used to characterize the total sample and for multiple choice questions and each item. Chi-square analysis was used to examine the difference between categorical variables. Results: 500 questionnaires were received out of 550. Most (62.2%) physicians assessed patients’ cancer pain every day, but 85.5% never or occasionally treated patients’ cancer pain together with psychologists. Most respondents appreciated that > 50% of patients with cancer experience severe chronic pain warranting analgesic therapy (73.5%), and that this therapy could control pain adequately in > 50% of patients (77.2%). More than half of physicians indicated that opioid dose titration in patients with poor pain control and assessment of the cause and severity of pain were urgently needed knowledge for cancer pain management. A majority (65.0%) of physicians responded incorrectly (60.0% agreed and 5.0% had no opinion) that they would increase the dosage of a potent opioid and administer it every 4 h as needed (q4h PRN). Inadequate assessment of pain and pain management (63.0%), patients' reluctance to take opioids (62.2%), and inadequate staff knowledge of pain management (61.4%) were the three most frequently barriers to physicians’ pain management. Conclusions: Our results revealed that physician education in cancer pain management in China does not currently provide the necessary levels of knowledge and skills. Therefore, effective strategies and professional education are still needed to encourage physicians’ concern with, experience in, and knowledge of cancer pain management in China.
How do they view us? Oncology providers’ perceptions of early/concurrent palliative care.
Authors: Babu Dilip Sankar , Dionne-Odom J Nicholas , Zubkoff Lisa , Smith Tasha , Bakitas Marie
Published: February 2017

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Background: Early integration of palliative care has been increasingly recognized as an important component in the care of cancer patients, including during active anticancer treatment. Yet, palliative and supportive care interventions remain to be well integrated into standard oncology practice. We sought to develop an original survey instrument in order to describe oncology providers’ perceptions of palliative care, particularly when introduced in the early and concurrent setting. Methods: We conducted a systematic review of literature pertaining to perceptions of palliative care and barriers to referral, and extracted survey items where they were found. This pool of questions was narrowed to focus on early/concurrent palliative care, and supplemented with original items. The draft survey was then systematically validated using a standardized scoring system and content-validity approach. Results: Twenty-two studies were reviewed. From an initial pool of fifty items, twenty-nine were selected for the draft survey. The draft was then reviewed by ten oncology providers, who scored each item and provided comments. Conclusions: We have produced a fully validated survey instrument that will be used to characterize oncology providers’ perceptions of early and concurrent palliative care interventions. The validated survey will be administered to oncology clinicians (including nurses, social workers and chaplains) at four academic medical centers at which an early palliative care intervention is currently being implemented. We hope to assess perceptions before and after implementation of the early palliative care intervention.
Development of provincial clinical standards for the province of Ontario.
Authors: Urowitz Sara , Marshall Denise , Myers Jeff , Bryant Deanna
Published: February 2017

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Background: The province of Ontario is committed to improving palliative care services. This commitment to change is outlined in The Declaration of Partnership, the provincial roadmap for improving palliative care. To help drive this change in the clinical environment, a Clinical Council for Palliative Care was established to be responsible for providing direction on clinical implications of policy, and advancing clinical improvement in palliative care in Ontario. To this end, Clinical Council has articulated a set of 12 interrelated provincial clinical standards which outline priority areas for clinical change and improvement in the province. Methods: Key stakeholder engagement was undertaken to identify evidence-based, best practices for delivery of palliative services. A consensus process was used to identify the priority set of essential clinical standards for high quality care that is both practical and scalable. Expert working groups were established to refine the standards based on evidence and leading or best practice to the Ontario context. Response was solicited from stakeholders, and qualitative analysis was conducted; standards will be refined based on feedback. Results: Based on the results of the stakeholder engagement, a “Clinical Change Strategy” was identified and a set 12 “clinical imperatives” were identified. Through the consensus process 12 Provincial Clinical Standards were endorsed. Conclusions: Engaging in an evidence informed process with key stakeholders has enabled the creation of a set of 12 interconnected Provincial Clinical Standards for palliative care in Ontario. These standards will help to advance high quality palliative care in the province. The standards represent a population health based strategy for change, which can have a positive impact at the systems level. Stakeholder feedback will result in further refinement of the standards, which will ultimately provide the foundation for standardized approaches for palliative services across Ontario.
Predictors of radiation therapy (RT) use among Medicare patients with metastatic non-small cell lung cancer (NSCLC).
Authors: Kim Miranda , Schrag Deborah , Li Ling , Chen Aileen B.
Published: February 2017

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Background: Palliative RT can improve quality of life, but also incurs time and financial costs. We evaluated factors associated with use and intensity of palliative RT for metastatic NSCLC. Methods: Using SEER-Medicare data, we identified patients diagnosed with pathologically confirmed stage IV NSCLC from 2004-2011. Receipt of RT and total fractions in the first RT course was collected. Univariable and multivariable logistic regression were used to identify factors associated with RT receipt and higher intensity RT ( > 10 fractions). Models were adjusted for clustering at the county level. Results: Among 53,371 patients with stage IV NSCLC, 39% (20,937) received palliative RT. Among patients receiving RT, 48% (10,048) received > 10 fractions and only 3.5% (724) received single fraction RT. On multivariable analysis, factors associated with greater RT use included younger age group (overall p < .01), lower Charlson comorbidity score (overall p < .01), female gender (OR 1.1, p < .01), married status (OR 1.1, p < .01), South (OR 1.0) and Midwest (OR 1.1) SEER region vs. Northeast (ref) or West (OR 0.9) (overall p < .01), higher radiation oncologist density tertile (OR 1.1, overall p = .02), hospice use (OR 1.47, p < .01), and chemotherapy use (OR 3.61, p < .01). Among patients treated with RT, predictors for > 10 fractions were older age group (overall p = .03), no hospice use (OR 1.1, p < .01), chemotherapy use (OR 1.9, p < .01) and freestanding vs. hospital-based RT facility (OR 1.66, p < .01). Conclusions: A combination of patient, treatment, and health service factors influenced whether a patient received palliative RT. In contrast, most patient factors (except age) did not influence the decision to treat with higher intensity radiation. The receipt of chemotherapy and treatment at a freestanding RT facility were highly predictive for extended RT fractionation, which may have been partially driven by higher reimbursement rates to freestanding facilities during this period.
Health disparities in advance care planning at a safety-net hospital.
Authors: Levin Elizabeth , Ries Michael , Rubins Jeffrey B , Wiernik Andres
Published: February 2017

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Background: Advance health care directives (AHCDs) are recommended by ASCO as a strategy to improve compliance with patient wishes at the end-of-life, thereby facilitating appropriate use of health care resources. We already know too few cancer patients complete AHCDs, but we know less about barriers to their completion. This study assessed the frequency with which AHCDs were completed in different ethnic groups and whether hospice enrollment varied by ethnicity. Methods: Retrospective analysis conducted at Hennepin County Medical Center in Minneapolis, MN with review of the cancer registry data from 2008 to 2013. Data were collected for deceased patients with stage III-IV cancer from the time of diagnosis through death. Demographics, AHCD, hospital deaths, enrollment in hospice, and individual patient data were analyzed using logistic regression, adjusting for both race and language as covariates. Results: From 2008 to 2013, there were 273 patients diagnosed with stage III-IV cancer and followed through death. Fourteen percent of patients were non-English speaking. Thirty-one percent were African American (AA), 4% were Hispanic, and 4% were Asian. Only 21% of patients completed an AHCD during their care, and none were Asian or Hispanic. English speakers were almost five times more likely than non-English speakers to have an AHCD (OR = 4.66, 95% CI = (1.06, 20.46), p = 0.04). Fifty-one percent of English-speaking patients enrolled in hospice compared to 39% of non-English-speaking patients (p = 0.08). Sixty percent of patients with an AHCD enrolled in hospice compared to 46% of those patients without an AHCD (p = 0.10). Forty-three percent of patients with an AHCD died in the hospital, 33% of whom died in an intensive care unit (ICU), versus 46% without an AHCD, 49% of whom died in an ICU. Of patients with advanced cancer, 46% died in the hospital and 21% died in the intensive care unit (ICU). Conclusions: Non-English-speaking patients are far less likely to have an AHCD than English speakers. Some ethnicities in our study had no patients with an AHCD. Since completing an AHCD may increase hospice enrollment and decrease ICU deaths, strategies to promote advance care planning are urgently needed, particularly with non-English speaking patients.