bluuebunny/crossref_metadata_2025 huggingface dataset:
Triple threat of mortality among advance cancer patients presenting to an emergency department.
Authors: Elsayem Ahmed F. , Warneke Carla L. , Reyes-Gibby Cielito C. , Page Valda D , Buffardi Luke Joseph , Brock Patricia A. , Chaftari Patrick , Alagappan Kumar
Published: November 2017

138

Background: Early identification of cancer patients with short survival will help address end of life issues and avoid costly interventions. Dyspnea, delirium, and poor performance are known to predict short survival in palliative care. Our goal is to test whether these 3 conditions could predict mortality in the emergency department (ED) setting because a shorter tool would be practical. Methods: We randomly selected 243 English-speaking patients with advanced cancer who presented to the MD Anderson hospital ED and who were judged clinically stable. Patients were assessed for the presence of delirium (Confusion Assessment Method and Memorial Delirium Assessment Scale), poor performance (Eastern Cooperative Oncology Group score 3 or 4), and dyspnea (MD Anderson Symptom Inventory shortness of breath score > 5). All measures (survival and symptom) were available for 212 patients. Triple threat was defined as the presence of one of more of the 3 conditions: delirium (by either tool), poor performance, or dyspnea. We obtained survival data from medical records. Results: The table below shows each condition frequency, predicted probability of 30-day survival, and median OS. In pairwise comparisons adjusting for multiple comparisons, participants with 2 or more of the symptoms had poorer 30-day survival and OS. Conclusions: Patients with advanced cancer who have at least two of the triple threat conditions should have early discussion of goals of care to avoid costly and aggressive interventions. Further research including clinically unstable patients should be performed. [Table: see text]
Access to early palliative care in a cancer center in Mexico.
Authors: Alcalde Castro Mirza , Soto Perez De Celis Enrique , Covarrubias-Gómez Alfredo , Navarro-Lara Africa , Sánchez-Román Sofía , Pérez-Montessoro Viridiana , De La O Murillo Andrea , León-Rodriguez Eucario , Chávarri-Guerra Yanin
Published: November 2017

139

Background: Early palliative care (PC) improves the outcomes of patients with advanced cancer, and ASCO has issued guidelines to encourage the integration of PC into standard oncology care. However, even in developed nations, many patients fail to obtain a timely PC evaluation. We reviewed current practices in the assessment of PC needs and use of PC services in a cancer center in a developing country. Methods: All patients with newly diagnosed advanced solid tumors seen at the National Institute of Medical Science & Nutrition in Mexico City from 10/2015 to 03/2016 were included. Demographic and clinical characteristics, data regarding assessment of PC needs, and referrals to PC services were retrospectively obtained from chart reviews for the first year after diagnosis. Frequencies and summary statistics were utilized. Results: 77 patients were included (median age 62 years; range 19-88; 55% male). 53% had gastrointestinal, 21% genitourinary, and 16% other tumors. The most commonly assessed symptom by oncologists (in at least one visit) was pain in 77% of patients, followed by anorexia (75%), fatigue (70%), nausea (57%), dyspnea (28%), and depression/anxiety (13%). 30% of patients were referred to PC in the first year after diagnosis. Median time from diagnosis to PC referral was 138 days (range 25-467). The most common causes for PC referral were pain (38%), delirium (23%), dyspnea (20%) and fatigue (20%). Only 1% of patients completed advance directives. 42% died during follow-up, of which 38% had previous PC visits. Median time from first PC visit to death was 15.5 days (range 1-70). Median time from last chemotherapy to death was 72.5 days (range 2-1201). Conclusions: Less than a third of the patients were referred to PC early in the course of their disease, and many PC needs were not routinely evaluated. Novel strategies are needed to improve access to early PC in developing countries.
Hospitalization costs for nausea and vomiting: A savings opportunity.
Authors: Roeland Eric , Ma Joseph , Binder Gary , Goldberg Robert , Paglia Robert , Knoth Russell L. , Schwartzberg Lee Steven
Published: November 2017

155

Background: Nausea and vomiting (NV) are tracked by CMS as 2 of 10 top drivers of potentially avoidable hospital admissions for patients with cancer. These admissions pose a savings opportunity, yet limited literature exists on the costs of chemotherapy-induced NV (CINV). Burke’s 2010 assessment of 19,139 patients from 2004-2007 found CINV hospitalizations cost $7,448 and comprised the majority of overall CINV events and costs vs ambulatory events. Rashid (2016) evaluated 1,682 patients with metastatic breast cancer from 2007-2011 and found CINV admissions cost $10,074 in 2013 US dollars. Using data from the US Agency for Healthcare Research and Quality ’s Healthcare Cost and Utilization Project website (HCUPnet), and after applying adjustment factors from recent literature, we evaluated the cost of NV hospitalizations. Methods: Data on US hospital discharges for NV (based on primary discharge diagnosis) were obtained for 2014 from HCUPnet. Charges were adjusted using Smith’s (2015) model showing commercial insurers paid 48.7% of their hospital charges. They were further modified to include professional fees equaling 26.4% of facilities paid amounts, as reported by Peterson (2015). The CPI-Medical rate was used to adjust costs to 2016 dollars. A US payer perspective was used. The proportion of total NV discharges due to CINV is not known; it is also unknown whether charges for CINV differ from those for NV overall. Results: HCUPnet reported 37,730 hospital discharges for NV, with mean charges of $23,603 per event. The mean payment to hospitals, after adjustment to reflect amounts insurers actually paid, was estimated at $11,232 per event. Adding physicians’ professional fees incurred in the hospital setting yet normally charged separately yielded a total hospitalization cost of $14,197 ($15,120 in 2016 US dollars). Conclusions: Hospitalization for NV is common and costly; adjusted paid amounts averaged > $15,000 per discharge, a level consistent with the CINV literature. This economic impact, in addition to the consequences for patients’ quality of life, suggests the need for continued advances in preventing CINV and optimizing compliance with national antiemetic guidelines, particularly for chemotherapy with high emetogenic potential.
Multidisciplinary osteoncologic approach to bone metastases: Analysis of a large, mono-institutional cohort.
Authors: Maruzzo Marco , Ahcene Djaballah Selma , Brunello Antonella , Falci Cristina , Zovato Stefania , Schiavon Stefania , Nena Ugo , Galuppo Sara , Parisi Alessandro , Aliberti Camillo , Ruggieri Pietro , Zagonel Vittorina
Published: November 2017

159

Background: Bone metastases are responsible for high morbidity in patients (pts) with a strong clinical impact. Recently, a new multidisciplinary approach called osteoncology has benn develped. No data on multidisciplinary management of large series of patients (pts) with bone cancer disease are available. Methods: We reviewed clinical data of all the consecutive pts evaluated from Apr 2013 to Dec 2016 in the multidisciplinary Osteoncology clinic of Istituto Oncologico Veneto. We collected clinical data on primary diasease, sites of disease, pain, bone clinical and radiological situation, assesment and medical decision taken in a multidisciplinary team. Results: 481 pts (303 F, 63%) have been evaluated by a multidisciplinary team composed by medical and clinical oncologist, pain specialist, endocrinologist, radiologist and ortopedic surgeon. Totally, 444 visits and 340 discussione have been performed. 422 pts (88%) had bone metastases, median age 65 years (range 34-89). 388 pts (92%) had vertebral metastases, 167 (39%) had pelvic bone disease, 201 (47%) had other site of bone disease including extremities. 186 (39%) pts had pain. We have prescribed a corset for 151 (31%) pts, radiation therapy for 202 (42%) pts with a median time from prescription to delivery of 15 days. Vertebroplastic has been prescribed in 66 (14%) pts with a median time for delivery of 7.5 days. 33 (7%) pts received indication to orthopedic surgery with a median waiting time of 15 days. For 115 pts data on pain at visit and 30 days later were available: 41 pts had no change in NRS, 11 pts had a worst paint (median NRS Δ = +2), 63 pts had a pain reduction (median NRS Δ = -3). 301 pts received a diagnosis of SRE. Median OS (mOS) was 80.9 months; at 2 yrs 91% of M0 pts vs 75.8% of M1 pts was alive (p = 0.0018); mOS for pts with a SRE was 70 vs 89.5 mos in pts without SRE (p = 0.033); among M1 pts, there was no significant difference from having or not a SRE. Conclusions: To our knowledge this is the first reported series of pts evalutated by an osteoncologic team. OS confirms that pts with SRE had a poorer outcome. Median time from prescrition to care delivery is shorter from data available in literature, conferming the positive impact for pts from multidisciplinary approach.
Optimizing dosing in navigation interventions across the cancer continuum: A planned secondary data analysis from the Patient Care Connect implementation.
Authors: Kvale Elizabeth Ann , Pisu Maria J , Williams Courtney , Kenzik Kelly , Azuero Andres , Sharma Pradeep , Halilova Karina I. , Rocconi Rodney Paul , Cantuaria Guilherme Henrique , Partridge Edward E. , Rocque Gabrielle Betty
Published: November 2017

174

Background: Patient navigation programs in cancer care have historically focused on assisting persons to overcome barriers to accessing care. Evidence is emerging to support the impact of navigation interventions across the cancer continuum. However, navigation programs have varied designs, resulting in a lack of clarity about the optimal approach to delivering services to patients, and a lack of evidence linking program design to outcomes. Methods: A planned retrospective analysis of Medicare administrative claims for a population of older beneficiaries diagnosed with cancer: The main exposure was the number of contacts in person or over the phone with PCCP navigators in the 6 month period starting from the quarter in which patients enrolled in the PCCP. Repeated measures generalized linear models with normal distribution were used to evaluate trends in total cost over time based on: number of contacts, quarters post-enrollment (TIME), and the interaction between number of contacts and TIME. Intra-correlation was controlled for repeated measures. Results: 4,337 patients were included in this analysis. 17.9% had one contact, 17.7% had two, 22.2% had 3-4, 24.2% had 5-10, and 18.0% had more than 10 contacts. African Americans had a greater number of participants with more than 10 navigator contacts, as stage 4 cancers, and initial or end-of-life phase of care. Patients who received more than 3 contacts had significantly higher levels of baseline cost. Models to evaluate total cost over time demonstrate an effect of navigator contact on cost that is associated with number of contacts. This trend is statistically significant at 3-4 contacts or more, and remains significant at 10 or more contacts. Conclusions: Increased navigator contact is associated with increased slope of decline in utilization and cost indicates that navigation programs should be adequately resourced to deliver care that enables navigators to have contact with patients a minimum of 3-4 contacts over a six month period.
Spirituality among Latino caregivers of patients with advanced cancer: A qualitative study.
Authors: Delgado-Guay Marvin Omar , McCollom Susana , Palma Alejandra , Duarte Eva Rossina , Grez Monica , Tupper Laura , Bruera Eduardo
Published: November 2017

180

Background: Caregivers of cancer patients often face significant physical, social, and emotional distress. There has been limited research on the association between Latino Caregivers’ spirituality/religiosity, meaning, and spiritual pain. Methods: We interviewed 336 Latino Caregivers of patients at Palliative Care clinics in Chile, Guatemala, and the US. Five open-ended questions were asked about spirituality, religion, meaning, and spiritual pain. Answers were transcribed and data analyzed. The analytic framework was based on an interpretive phenomenological analysis. Initial themes were grouped into themes, connections between themes were developed until a thematic rationale was achieved. Results: Latino caregivers’spirituality and religious beliefs were described as an anchor during the painful witnessing of a loved-ones’suffering. Main themes emerged about relationships, inner strength, hope, and acceptance/reconciliation. It was reported as an integrative force to help them to cultivate hope and love walking through their love one’s illness and their journey as caregivers. They expressed meaning as a manifestation of spirituality together with their love to others(spouse, family, others). The presence of Spiritual Pain was common and manifested as suffering and potential loss of loved ones, and broken relationship with Higher Power, that triggered a profound experience of their own pain(both spiritual and emotional) and their own quality of life. This was expressed in physical terms such as “heartache” and “soul ache.” Through discernment, prayer, and relationships with loved-ones, spirituality was integrated as a healing force during the caregiver journey. Spirituality was reported as a substance of hope weaved into an integrative process, as caregivers reconciled the tension of faith with sorrow. Conclusions: Spirituality and religious beliefs are reported as fundamental for Latino Caregivers. Despite these elements, Spiritual Pain is common and affects all aspects of their humanity. Most of them experienced a reconciliation experience with the broken relationships with themselves, with others or with Higher Power.
Integration of spiritual care services along with supportive care clinic in a comprehensive community cancer center.
Authors: Chandra Abhinav Binod , Carlson Laree , Alvarez Angelic , Kumar Vivek , Elnadry Jeanne
Published: November 2017

181

Background: A grave illness like cancer can lead to substantial spiritual distress for patients and their care givers. Not meeting patients’ spiritual needs have been reported to lower ratings of quality and dissatisfaction with care. The FACIT-Sp-12 is used in research studies investigating health related quality of life (HRQOL) outcomes in cancer patients and has special focus on faith, meaning and peace. Methods: We introduced a unique model at the cancer center by having the chaplain resident and pain/palliative care physician evaluating and following patients together during the weekly Supportive Care Clinic. FACIT-Sp-12 score was also calculated for 92 patients on 164 visits during October 2016 till July 2017. Results: Overall, the FACIT-Sp-12 score was calculated for 92 (52 females and 40 males) patients with median age of 69 years (range 36-89). Sixty-eight (74%) were non-Hispanics while native language was English for 71 (77%) patients. The baseline FACIT-sp-12 score ranged between 16 and 48 with median score of 38. Thirty-two patients had follow up visits. 15 of these patients had improvement in their FACIT-Sp-12 score, 12 patients’ score had decreased and 5 patients’ scores were unchanged. There was an increase in FACIT-Sp-12 score in the males but after adjusting for gender, age, race, language and number of follow up visits, none of the variables could predict increase in the FACIT-Sp-12 score. Conclusions: We have successfully implemented this model of integrating spiritual support services to the delivery of cancer care. Decrease in FACIT score may coincide with distress associated with worsening symptoms or change in patient’s condition, and offers an opportunity to address the increased spiritual needs and assistance with coping during times of distress. Future prospective studies will prove instrumental in validating this approach and hopefully become a service reimbursable by health insurances, and thereby become universally accessible.
Exploring the relationship of self-reported lack of appetite to patient characteristics and symptom burden.
Authors: Hyland Kelly , Fenech Alyssa L , Portman Diane , Donovan Kristine A.
Published: November 2017

187

Background: Cancer anorexia-cachexia syndrome (CACS) in patients is associated with decreases in lean body mass and body weight. Self-reported lack of appetite may be an important indicator for early identification of CACS. The current analyses examined the relationship of perceived lack of appetite to patient characteristics and overall symptom burden in a large mixed cancer sample referred to a palliative care clinic. Methods: We conducted a retrospective review of patients newly referred to an outpatient palliative care clinic over a two-year period. Data on demographic and clinical characteristics and patient-reported symptom scores on the Edmonton Symptom Assessment Scale (ESAS) were abstracted. Pearson’s correlations and ANOVAs were used to assess relationships between variables. Multiple regression analysis was used to evaluate the relative contribution of variables that were significantly correlated with lack of appetite at the univariate level. Results: Data on 544 patients ( M=53.7 years) showed that older age (r=12, p<.01), not being married or in a marriage-like relationship (r=.09, p=.04), having insurance other than managed care insurance (r=.10, p=.02), lower body mass index (BMI; r=.11, p<.01), marijuana use (r=.18, p<.0001), and overall symptom burden (ESAS total score r=.52, p < .0001) were associated with worse lack of appetite ( M=3.5, SD=3.1). Patients who were underweight (BMI <18.5, 46.7%) reported significantly worse lack of appetite than patients who were normal weight, overweight, or obese ( M=3.9, SD=3.2, p<.01). The final hierarchical regression model accounted for 34% of the variance in lack of appetite, with age, marital status, BMI, marijuana use, and total symptom burden remaining significant independent correlates (p’ s <.01). Conclusions: Contrary to expectations, relatively few clinical correlates were associated with self-reported lack of appetite. Future research should explore inter-individual genetic factors to explain alterations in lean body mass and body weight that may contribute to poor appetite in patients. Such factors may be important indicators for early identification of CACS.
Meditation as a doula-delivered intervention for underserved late-stage cancer patients: A feasibility trial.
Authors: Moadel Alyson B. , Camacho Fernando J. , Schlecht Nicolas
Published: November 2017

188

Background: Socioeconomic disparities in psychosocial outcomes among cancer patients have been documented. High interest in peer support and mind-body therapies across diverse populations presents an opportunity for enhancing end-of-life care in the underserved setting. We present the results of a psychosocial needs assessment, and the findings from a feasibility trial in which peer navigators (PN; cancer survivor volunteers) were taught to deliver Loving Kindness (LK) Meditation in preparation for their role as end-of-life “Doulas”. Methods: (1) A survey of psychosocial symptoms and needs was administered to a convenience sample of 56 stage IV patients from an NCI-designated cancer center in Bronx, NY. Patients were female (75%), African American (43%), Hispanic (45%), and 56 M years old. (2) A feasibility trial randomly assigned 9 patients to receive LK meditation delivered by 1 of 4 trained PNs or a professional meditation instructor. The trial was rated on 8 measures of feasibility as set forth by Bowen et al 2009. Results: Patients reported high sadness (66%), anxiety (54%), anger (41%), and spiritual distress (18%) with 70% endorsing an interest in mind-body therapies “such as meditation”, and 46% an interest in a PN. In the LK meditation feasibility trial, patients reported improved positive affect scores by a clinically significant margin of 13%, with equivalent impact and satisfaction for PN relative to professional instructor. Conclusions: Inner city late stage cancer patients endorse high distress, and high interest in peer support and mind-body interventions. Feasibility testing demonstrates that LK meditation is responsive to patient preference and demonstrates preliminary efficaciousness. Findings suggest that Doula-delivered meditation for underserved patients presents a unique resource in the palliative care setting.
Is stereotactic radiosurgery of brain metastases in patients with poor performance status worthwhile?
Authors: Ampil Federico , Kim Donghyun , Richards Troy , Vora Moiz , Mills Glenn Morris , Nanda Anil
Published: November 2017

192

Background: Performance status is a consistent predictor of outcome in people with advanced disease. Variable prognosis has not led to the exclusion of patients with Karnofsky performance scores of < 70 from treatment of brain metastases (BRM) with stereotactic radiosurgery (SRS). The role of SRS for BRM in individuals with poor performance status (PPS) has not been elucidated to date. To better understand the prognostic utility of SRS in this particular patient cohort, we assessed the longevity periods of our treated PPS subjects with BRM. Methods: A retrospective review of patients with BRM treated by SRS during a 10-year period (2000-2009) identified 22 adult individuals with PPS; PPS was defined by the presence of severe hemiparesis or cerebellar ataxia. The primary endpoint of the analysis was survival because of some limitations in the obtained data. The mean follow-up was 26 months (range: < 1 to 144 months). Results: The mean age was 55.8 years, and the majority of the subjects were female. Most of the patients were younger and diagnosed with solitary brain metastasis. The synchronous primary malignant tumor was not yet under control in a third of the patients, and extracranial metastases were noted in 45% of the subjects. Thirteen people (59%) died within two months after therapy, and nine patients (41%) lived for two years or longer. The overall crude survival rates at 1 year and 5 years were 41% and 18%, respectively. Treatment response information was not available in the short-survival group because of early demise. Intracranial tumor control was achieved in the long-term survivors, considering that BRM progression requiring repeat SRS was not observed in any instance. Characterization of the two groups with different longevities was not possible. Conclusions: Early mortality was not predominant in this limited experience, and the observed prolonged survival suggests that SRS still represents a valuable treatment option for individuals with PPS and BRM.
Opioid utilization patterns among patients with cancer and noncancer pain.
Authors: Datto Catherine J. , Hu Yiqun , Wittbrodt Eric , Fine Perry G.
Published: November 2017

194

Background: Opioids are used to manage moderate to severe pain in patients with cancer and non-cancer pain. Limited data exist comparing opioid utilization patterns between these two patient populations. Methods: This retrospective, commercial administrative claims database analysis (HealthCore Integrated Research Environment) investigated opioid use patterns, including opioid dose escalation, in adult patients with cancer-related (CP) and non-cancer-related pain (NCP). Adults (age ≥18 years) with at least one pharmacy claim for an opioid between July 1, 2006, and September 30, 2014, were identified (index date). Patients selected for analysis had to have continuous plan eligibility for 6 months pre- and 12 months post-index date and opioid use for at least 4 weeks. Patients with opioid use related to cancer pain were identified by a medical claim for a cancer diagnosis coded within 30 days prior to the index opioid date. Results: A total of 9,209 patients with CP and 409,703 patients with NCP were analyzed. Patients with CP were older than patients with NCP (mean [SD]: 62.6 [12.9] yrs vs. 49.3 [15.3] yrs); other demographics were similar between cohorts. The most common cancer diagnoses were breast, lung, and prostate. Hydrocodone was the most common opioid prescribed for both cohorts. Total mean (SD) days of opioid therapy were 167.1 (341.8) for CP and 196.6 (421.1) for NCP, with similar rates of opioid use for ≥1 year (10.6% for CP; 13.6% for NCP). Median index opioid doses were consistent between the cohorts (CP: 51.7 morphine-equivalent units (MEU); NCP: 45.0 MEU). Median post-index (after the first 30 days) opioid doses were also similar (CP: 55.8 MEU; NCP: 45.3 MEU). Post-index opioid dose reductions occurred in approximately one-third of both cohorts. Opioid dose escalations (up to dose doubling) occurred in 31.8% of CP and 28.3% of NCP patients. More patients died during the follow-up period in the CP cohort (24.1%) compared with the NCP cohort (0.02%). Conclusions: The use of opioids bears many similarities between patients with cancer pain and non-cancer pain, including clinically similar rates of chronic opioid utilization and dose escalation. This study was supported by AstraZeneca.
Risk of suicide in persons with gastrointestinal cancer: A population-based study.
Authors: Deng Aileen , Basu Mallick Atrayee
Published: November 2017

197

Background: Patients with cancer have nearly twice the incidence of suicide compared to the general population(1). To date, identifying patients at risk for suicide remains challenging. The purpose of this study was to identify risk factors of suicide among patients with GI cancer. Methods: A retrospective analysis was completed using Surveillance, Epidemiology, and End Results data from 1973 to 2014. Comparisons with the general US population were based on US mortality data collected by the National Center for Health Statistics. Suicide incidence, rates and standardized mortality ratio (SMR) were obtained by SEER*Stat 8.3.4. Results: Among 711859 patients with GI cancer observed for 3373014 person-years, 1116 suicides were identified, for an adjusted suicide rate of 33.1/100,000 person-years (SMR 1.74 [95% CI 1.64-1.85]). The highest suicide risks (SR) were in esophageal (SMR 5.42 [95% CI 4.30-6.75]), pancreatic (SMR 4.91 [95% CI 3.83-6.19]) and liver or intrahepatic biliary cancer (SMR 3.36 [95% CI 2.35-4.65]). Higher SRs were associated with unmarried status, age 40 years and older at diagnosis and the first 5 years after diagnosis. In esophageal (EC) and pancreatic (PC) cancer, SR was 8 folds higher in unmarried patients compared to the general population with a SMR of 8.31 [95% CI 5.68-11.73] and 7.68 [95% CI 5.18-10.97], respectively. In EC and PC, SR was highest in patients > 80 years (SMR 7.09 [95% CI 3.40-13.03]) and 40-59 years at diagnosis (SMR 7.10 [95% CI 1.93-18.18]), respectively. Patients have especially high SR the first year after diagnosis in EC (SMR 10.25 [95% CI 7.65-13.44]) and PC (SMR 7.72 [95% CI 5.83-10.03]). Conclusions: While overall, patients with GI cancer have nearly twice the SR, those with certain cancer subtypes have up to 5 times the SR when compared to the general population. SRs are highest in esophageal, pancreatic and liver or intrahepatic biliary cancer. Suicide screening should especially target patients with EC and PC who are unmarried or lack a support system and within the first year after cancer diagnosis.
A systematic review and meta-analysis of randomized controlled trials to evaluate the risk of fatigue and pain among patients treated with ibrutinib.
Authors: Zaw Myo , Thein Kyaw Zin , Han Myat M. , D’Cunha Ruth , Kaleem Hassan , Hardwicke Fred L. , Tijani Lukman
Published: November 2017

213

Background: Bruton’s tyrosine kinase (BTK), a kinase downstream of the B-cell receptor, involves in the B cell survival and proliferation and has become an attractive therapeutic target. Ibrutinib is an oral potent, covalent inhibitor of BTK and hence employed in many hematologic malignancies. We performed a systematic review and pooled analysis of randomized controlled trials (RCTs) to determine the risk of fatigue and pain among patients treated with ibrutinib. Methods: We performed a comprehensive literature search using MEDLINE, EMBASE databases and meeting abstracts through December 31, 2016. RCTs that mention fatigue, arthralgia, muscle spasm, back pain, pain in extremity and myalgia as adverse effects were incorporated in the analysis. Mantel-Haenszel method was used to calculate the estimated pooled risk ratio with 95% confidence interval (CI). Results: Four phase 3 RCTs with a total of 1505 patients were eligible for the analysis. Studies compared Ibrutinib (I) vs ofatumumab, I vs chlorambucil, I+ bendamustine (B)+ rituximab (R) vs placebo + B+ R and I vs temsirolimus were included in the analysis. The relative risks (RR) of all-grade side effects were as follows: fatigue, 0.87 (95% CI: 0.74- 1.03, p = 0.11); arthralgia, 1.97 (95% CI: 1.11- 3.50, p = 0.02); muscle spasm, 1.92 (95% CI: 1.22- 3.02, p = 0.005); back pain, 1.56 (95% CI: 1.02- 2.37, p = 0.03); pain in extremity, 2.47 (95% CI: 1.14- 5.36, p = 0.02); and myalgia, 2.68 (95% CI: 1.18- 6.05, p = 0.01). The RR of high-grade side effects were as follows: fatigue, 0.70 (95% CI: 0.37- 1.33, p = 0.28); arthralgia, 3.62 (95% CI: 0.74- 17.66, p = 0.11); back pain, 2.80 (95% CI: 0.42- 18.35, p = 0.28); pain in extremity, 2.96 (95% CI: 0.31- 28.4, p = 0.34); and myalgia, 2.96 (95% CI: 0.31- 28.44, p = 0.34). Conclusions: Our meta-analysis demonstrated that the risk of all-grade arthralgia, muscle spasm, back pain, pain in extremity and myalgia with ibrutinib was high. Pain is a major determinant of quality of life in cancer patients undergoing chemotherapy and recognizing these may help clinicians in delivering proper supportive care.
Trismus and reduced quality of life in patients with oral squamous cell carcinoma who received postoperative radiotherapy alone or combined with chemotherapy.
Authors: Nicolatou-Galitis Ourania , Psyrri Amanda
Published: November 2017

222

Background: Patients, who receive radiotherapy (RT) for head and neck cancer, develop chronic functional abnormalities and reduced mouth opening-trismus, surviving with reduced quality of life (QoL). We aimed to study trismus and QoL in patients with oral cancer, who received post-operative radiotherapy or chemoradiotherapy. Methods: Patients, who receive radiotherapy (RT) for head and neck cancer, develop chronic functional abnormalities and reduced mouth opening-trismus, surviving with reduced quality of life (QoL). We aimed to study trismus and QoL in patients with oral cancer, who received post-operative radiotherapy or chemoradiotherapy. Results: Mean RT dose was 64.3 Gray. Six patients received chemoradiotherapy. Severe mucositis, pain and xerostomia were recorded in 6 and 5 patients respectively. MMO was reduced in all patients. The mean MMO (34 mm) reached the level of trismus. The total number of symptoms increased from 3.1 to 6.3 in C-30 and from 3.1 to 8.8 per patient in the H/N35. Severe fatigue, pain, limitations at work, weakness, sad feelings, family problems, sleeping problems, anorexia, financial difficulties, tense/irritable, constipation, nausea, vomiting and depression were most often reported with C-30. Most patients reported poor to moderate quality of life. Severe oral, jaw and neck pain, swallowing problems, taste alterations, sticky saliva, dry mouth, coarseness, dental problems, feeling sick and reduced interest in life/sex were the most common symptoms reported with N/H35. Conclusions: The observed trismus, the 2- to 3-fold increase of symptoms and poorer quality of life highlighted the need for support of oral cancer patients, who receive postoperative radiotherapy or chemoradiotherapy. Reduced systemic health, financial difficulties and family problems could be some of the main reasons for the inadequate compliance of our patients to the study, as shown by others, too. The strength of our study was the homogeneous group of patients: all had oral squamous cell carcinoma and all received post-operative radiotherapy or chemoradiotherapy. The small number of patients represents a weakness.
Frequency and factors predicting the risk for aberrant opioid use in patients receiving outpatient palliative care at a comprehensive cancer center.
Authors: Yennu Sriram , Edwards Tonya , Arthur Joseph Anthony , Lu Zhanni , Najera John M , Nguyen Kristy , Rodriguez Eden Mae , Joy Manju P , Kuriakose Leela , Wu Jimin , Liu Diane D , Williams Janet L. , Reddy Suresh , Bruera Eduardo
Published: November 2017

228

Background: Opioid misuse is a growing crisis among patients with chronic pain. Cancer patients at risk of aberrant drug behaviors (ADB) are frequently underdiagnosed in routine cancer care. The aim of this study was to determine the frequency and factors predicting risk for Aberrant Opioid and Drug use among Patients receiving Outpatient Supportive Care Consultation at a Comprehensive Cancer Center Methods: In this retrospective study, 690 consecutive patients referred to a supportive care clinic were reviewed. Patients were eligible if they were ≥18 years, had a diagnosis of cancer, and were on opioids for pain for atleast a week. All patients were assessed with the Edmonton Symptom Assessment Scale (ESAS), SOAPP-14, and CAGE-AID. At risk patients with aberrant opioid behavior (+Risk) was defined as SOAPP-14 score ≥7. Descriptive statistics, spearman correlation coefficient, multivariate analysis were performed. Results: 690/752 consults were eligible. A total of 135(20%)were +risk. 69(11%) were CAGE-AID +.SOAPP-14 scores were positively associated with CAGE-AID p < 0.001; male gender p = 0.007; ESAS pain p = < 0.006; ESAS depression p < 0.001; ESAS anxiety, p < 0.001, and ESAS financial distress p = < 0.001. Multivariate analysis indicated that the odds ratio for +Risk was 2.47 in patients with CAGE-AID+ (p < 0.001), 1.95 for male gender (p = 0.005), 1.11 per point for ESAS anxiety (p = 0.019), and 1.1 per point. for ESAS financial distress (p = 0.02). Conclusions: 20% of cancer patients on opioids presenting to supportive care center are at risk of aberrant drug behavior. Male patients with anxiety, financial distress, and prior alcoholism/illicit drug use are significant predictors of +Risk. Further research to effectively manage these patients is needed.
Effect of palliative surgery, chemotherapy, and radiation in stage IV pancreatic cancer.
Authors: Vuong Brooke , Dehal Ahmed , Graff-Baker Amanda , Chang Shu-Ching , Foshag Leland Jay , Bilchik Anton , Goldfarb Melanie
Published: November 2017

233

Background: Despite significant advances in multi-modality treatment for pancreatic adenocarcinoma (PC), prognosis for stage IV PC remains poor. While reducing suffering and optimizing quality of life are the primary goals of palliative therapies, these interventions may extend overall survival. We examined the impact on survival when aggressive palliative treatments including surgery, chemotherapy, or radiation were employed in end-of-life care. Methods: The 2004-2014 National Cancer Data Base (NCDB) was queried to identify patients with stage IV PC that did not undergo primary surgical resection. Univariate (Kaplan Meier and log-rank) and multivariable (Cox proportional hazard) analyses were used to assess the associations between patient characteristics, use of palliative therapies, and overall survival. Results: Of 72,736 patients identified with metastatic stage IV PC, 2,097 (3%) underwent surgical palliation (ST), 5,615 (8%) received palliative chemotherapy (CT), 940 (1%) received palliative radiation (RT), 1,163 (2%) received multimodality treatment (MMT), and 62,921 (87%) had no aggressive palliative intervention (NT). The choice of palliative therapy, if any, was influenced by all demographic and tumor variables except for gender (all p < 0.001). Median OS was greatest after CT (5.09 months, p < 0.001) compared to any other modality (NT: 3.45months, ST: 3.71months, RT: 3.25months, MMT: 4.47months). This remained true regardless of age, gender, race/ethnicity, insurance, and facility type. After adjusting for all demographic and tumor factors, use of CT decreased the annual risk of death by 20% (HR = 0.8; 95%CI [0.77, 0.82]) and MMT by 10% (HR = 0.9; 95%CI [0.84, 0.96]). Employment of RT increased risk of death by 9% (HR = 1.09; 95%CI [1.01, 1.17]) and ST did not affect OS (HR = 1.01; 95%CI [0.96,1.06]). Conclusions: Despite advances in palliative treatments, Stage IV PC arries a dismal prognosis. Palliative RT may shorten survival. Equivalent survival for ST versus NT suggests that this may be beneficial in the appropriate patient. Palliative CT independently improved survival by approximately 6 weeks and should be considered in patients that want to extend survival and can tolerate the toxicity.
Health providers’ perspectives on medical marijuana use.
Authors: Martins-Welch Diana , Nouryan Christian , Kline Myriam , Modayil Sony
Published: November 2017

235

Background: According to the CDC, 117 million Americans have one or more chronic health conditions and 31% have used two or more prescription drugs in the past month. Approximately 40% of adults in the United States are using some form of Complementary and Alternative Medicine. Medical marijuana is one such medicine, and to date 29 states have legalized medical marijuana. Methods: A multicenter, anonymous, on-line survey of health care providers was distributed via e-mail within a large health system in the NY Metropolitan area. The survey was distributed in April and May of 2017. The specific aim was to collect information about health care providers’ perspectives on the use of MM in general and for specific medical conditions. Results: The sample (n = 137) consisted of 4% RNs, 10% NPs, 10% fellows, 21% resident physicians, and 52% attending physicians. Average experience was 13 years (range: 0-43), half (53%) were under 40 years old and just over half (56%) were female. Most practitioners recognized a benefit of MM for the treatment of cancer-associated symptoms, few were concerned with side effects and 5% of responders answered that MM was not appropriate at any stage of illness. Responders were “most likely to recommend or refer MM if other therapies were not effective” for cancer (83%), chronic pain (68%), spinal cord injury with spasticity (50%), MS (46%), epilepsy (42%), neuropathy (42%) and Parkinson’s disease (41%). Most providers (77%) believed that MM has the potential to reduce overall opioid use, this was found to be statistically more common in younger providers. The most common conditions that providers reported their patients were requesting MM for were cancer (37%), chronic pain (26%) and neuropathy (10%). The most common concerns about MM use were side effects (16%), addiction (13%), legal consequences (11%), cost (7%) and that other providers would judge MM use (7%). Conclusions: Our survey shows that providers are overwhelmingly in support of MM use in patients with chronic illness, particularly in cancer patients. However providers describe significant and practical concerns about MM utilization. Given the rate at which MM is being legalized throughout the country, it is imperative that there be increased focus on education and clinical studies on MM.
Common AEs associated with CDK4/6 inhibitors in patients with hormone receptor–positive advanced breast cancer.
Authors: Yardley Denise A.
Published: November 2017

239

Background: Cyclin-dependent kinases 4 and 6 (CDK4/6) inhibitors combined with letrozole or fulvestrant substantially prolong progression-free survival (PFS) with a well-tolerated, predictable safety profile. Understanding the safety profile of selective CDK4/6 inhibitors can inform adverse event (AE) management and can extend and maintain time on treatment. Here, we report common AEs associated with CDK4/6 inhibitors and perspectives on monitoring as well as managing these AEs. Methods: We reviewed 5 published Phase II/III trials of ≥50 patients with advanced breast cancer (ABC) treated with CDK4/6 inhibitors in combination with endocrine therapy with respect to commonly reported AEs, defined as AEs reported in ≥15% (any grade) or ≥5% (Grade 3/4) of patients in ≥4 of 5 trials. Results: The most common AEs consisted of hematologic, gastrointestinal, and general well-being AEs (Table). Nonhematologic AEs were mostly Grade ≤2 and easily managed with dose modification. Uncomplicated neutropenia was the most common hematologic AE and was noncumulative, with the lowest neutrophil counts typically reached within a month of initiating treatment, and did not require intervention. Median time to resolution of Grade 3 neutropenia was 7–15 days. Febrile neutropenia was rare (<2%). Conclusions: CDK4/6 inhibitors are characterized by early, predictable, easily managed, transient AEs that do not require intervention. Awareness of and patient support for these AEs can enable patients with ABC to remain on CDK4/6 treatment and achieve associated PFS benefits. [Table: see text]
Stereotactic body radiation therapy for palliative treatment of bone metastases: Practice patterns and survival outcomes.
Authors: Kinchen Catherine Lee , Taylor Trent N , Johnstone Candice Aitken , Robbins Jared R.
Published: November 2017

242

Background: Stereotactic body radiation therapy (SBRT) is an emerging modality of treatment designed to deliver high radiation doses in few fractions. We examine practice trends in the use of SBRT for managing bone metastases in patients with breast, kidney, non-small-cell lung, melanoma, or prostate cancer. Methods: We selected patients from the National Cancer Database (2004-2013) diagnosed with bone metastases from breast, kidney, non-small-cell lung, melanoma, or prostate cancer. SBRT fractionation regimens were defined as 12-45 Gy in 1 fraction, 14-50 Gy in 2 fractions, 21-50 Gy in 3 fractions, 28-50 Gy in 4 fractions, and 30-60 Gy in 5 fractions. Standard palliative radiation fractionation regimens were defined as all other cases with 2-40 Gy in 20 fractions or fewer. Results: Patients receiving SBRT regimens made up 1454 of 57,556 total palliative cases. Bone metastases treated with SBRT primarily at the spine (65.5%), hip/pelvis (12.3%), and shoulder/extremity (11.4%). SBRT palliation regimens were used for only 2.5% of patients. Though standard palliative radiation fractionation regimens comprised the majority of treatments (97.5%), SBRT utilization is increasing, with a majority (68.4%) of SBRT cases occurring from 2009-2013. Treatment at an academic center and lack of comorbidities were positively associated with receiving SBRT regimens. Mean survival outcomes were higher for patients receiving SBRT (24.3 months) than patients receiving standard regimens (16.9 months). Conclusions: Though the vast majority of bone metastases were treated with standard palliative radiation fractionation, SBRT utilization increased from 2004-2013, with the greatest portion of SBRT cases occurring at academic institutions. Patients receiving SBRT exhibit better survival outcomes, likely as a result of patient selection practices.
Scrambler therapy for the treatment of chronic central pain due to cavernous hemangioma in the midbrain: A model for treating central cancer pain.
Authors: Smith Thomas J. , Mealy Maureen A , Erdek Michael A. , D'Amato Steven , Kozachik Sharon
Published: November 2017

244

Background: Central pain syndromes are caused by damage to the sensory pathways of the central nervous system (CNS) within the brain or spinal cord, and are estimated to affect several million people worldwide. This can occur with malignant or benign brain tumors, or after surgery or radiation. The pain impulse is generated centrally but the pain is felt peripherally. Treatment is unsatisfactory with no universally accepted method of relief. Methods: A 52 year old woman had central pain manifest as burning pain from her left foot to the knee for 12 years. This happened after suboccipital craniectomy and C1 hemilaminectomy for a medullary cavernoma diagnosed after a right-sided brainstem bleeding episode due to a mulberry hemangioma, in 2004. The pain was minimally responsive to multiple neuropathic pain agents. Results: In early 2017, she underwent ten daily Scrambler (Calmare) Therapy treatments with reduction in her pain from 9-10/10 to 0-0.5/10 and was able to discontinue all her pain medications. Her pain recurred after a month but was again controlled to 1-2/10 with just two additional daily treatments, and remains controlled at three months. Her function and quality of life is much better. She has had no side effects. Conclusions: Scrambler (Calmare) Therapy may be an effective, safe, and non-invasive way to treat central pain from benign and malignant brain tumors, and/or their treatment, and deserves further study.
Standardizing opioid prescribing practices for cancer-related pain via a novel interactive documentation template at a public hospital.
Authors: Nusrat Maliha , Parkes Amanda Marie , Hu Bei , Farhat Dalia , Rieber Alyssa G. , Ma Hilary Y.
Published: November 2017

253

Background: Aberrant opioid use during treatment of cancer related pain poses serious risks for patients and society. Identifying and monitoring those at risk is challenging and time consuming. We aimed to standardize the process of managing opioids at a public hospital oncology clinic in compliance with Texas (TX) state regulations to improve patient safety. Methods: We gauged the current practices of assessing and documenting opioid efficacy, toxicity and misuse via provider survey and chart review. A process flowchart was then created and streamlined in the light of: published literature, TX Administrative Code on pain management, and practices of palliative care specialists at MD Anderson Cancer Center, TX. We made an interactive documentation template (SmartPhrase) in electronic medical record system (EPIC) to implement the standardized process. Results: Pre-intervention data showedhigh inter-provider variability in opioid misuse screening, safety monitoring and documentation. Of the 22 providers surveyed, 6 (22%) had a TX PMP Aware login; 8 (36%) ever checked the website; and 19 (86%) stated the need of a standardized process for prescribing opioids. Hence, we instituted baseline screening for aberrant behavior based on substance abuse history, TX PMP Aware query and urine drug screen; increased monitoring of high risk patients; universal screening for chemical coping at each visit; and timely referral of such patients to palliative care. We created a SmartPhrase that prompts providers to risk stratify and monitor for opioid misuse as above; assess analgesic efficacy; evaluate and manage uncontrolled pain and toxicities; and specify a refill plan. This SmartPhrase allows quick selection of options pertinent to a given patient from pre-populated lists before the encounter can be closed. Conclusions: We created a systematic approach to prescribing and monitoring opioid analgesics so as to ensure safe and judicious use of opioids to treat cancer related pain. We generated an interactive SmartPhrase for efficient documentation compliant with TX state regulations. Post-implementation review of efficacy and use of this intervention is ongoing to further refine it.