bluuebunny/crossref_metadata_2025 huggingface dataset:
Dosimetric study of 3-dimensional conformal radiotherapy, electronic compensator technique, intensity modulated radiation therapy, and volumetric arc therapy in whole-breast irradiation.
Authors: Nantavithya Chonnipa
Published: February 2017

44

Background: Whole breast irradiation is an essential treatment after breast conserving surgery (BCS). Adverse effects are from inhomogeneity of PTV and excessive dose to normal tissues. Aim of this study is to compare dosimetry among standard technique, three-dimensional Conformal Radiotherapy (3D-CRT) and advanced techniques, Electronic Compensator (ECOMP), Intensity Modulated Radiation Therapy (IMRT) and Volumetric Arc Therapy (VMAT). Methods: Images from CT simulation of patients who underwent BCS were replanned. Clinical Target Volume (CTV) was contoured followed RTOG atlas as breast only and breast with chest wall respectively. Planning Target Volume (PTV) was expanded 0.7 cm from CTV. Each patient was replanned with all four techniques. Dose prescription was 50 Gy in 25 fractions. Results: Twenty five patients underwent CT simulation from November 2013 to November 2014 were included. Six patients with node positive were planned for breast with chest wall irradiation and 19 patients with node negative were planned for breast only irradiation. Primary outcome, homogeneity index (HI) of 3D-CRT, ECOMP, IMRT and VMAT were 0.865, 0.889, 0.890 and 0.866 respectively which ECOMP and IMRT were significant higher than 3D-CRT (p values < 0.001). Secondary outcome, conformity index (CI), Mean heart dose (MHD), heart V25, heart V30, mean lung dose (MLD), mean ipsilaterallung dose (MILD), mean contralateral lung dose (MCLD) and mean contralateral breast dose (MCBD) of advanced techniques were significant better than 3D-CRT technique. Conclusions: HI of ECOMP and IMRT were statistically significant higher compared with 3D-CRT technique. Advanced techniques showed statistically significant superior in CI dose to heart, lungs and contralateral breast.
Electrochemotherapy for cutaneous metastases in breast cancer: Experience from a designated treatment centre.
Authors: Banerjee Shramana Mitul , Newby Jackie , Khan Shahab , Homfray Virginia , Whittaker Diane , Keefe Christopher , Keshtgar Mohammed R.
Published: February 2017

48

Background: Electrochemotherapy (ECT) combines the administration of poorly permeable chemotherapeutic agents with electroporation. It has been shown to be effective when compared with other treatments. This study assessed how breast cancer patients were benefited and identified potential problems at a designated treatment centre. Methods: This was a single centre prospective study of patients with cutaneous metastases from breast cancer. Patients who fulfilled NICE UK (National Institute Of Clinical Excellence) and local guidelines were treated. Gabapentin was given prior to general anaesthesia. Intravenous Bleomycin 15,000IU/m2 was given as a bolus. Treatment was commenced 8 minutes later with Cliniporator. Electrical pulses were delivered via an electrode inserted through the skin surface. Treatment response, disease progression free duration, post-operative pain and length of in-patient stay (LOS) were recorded. Patients recorded a symptom diary post treatment. Results: 20 treatments were performed in 16 patients from 2011-2015 with 53 separate areas treated. 8 patients had diffuse lesions, 5 had discrete lesions and 3 had both diffuse and discrete areas. 16 patients were being treated with ECT for the first time and 4 patients required 2 treatments. Median LOS was 3 days. Median follow up was 6 months (range 3-12).12 patients had complete response (75%) and 4 patients partial response. There was no disease progression for 6 months or more in 9 patients (56%) and 2 further patients had disease stabilised for 3 months with systemic or cutaneous progression in the remaining patients in 3 months or less. There were no deaths or immediate adverse events from ECT. 5 Patients (31%) with extensive diffuse chest wall disease reported persistent discomfort post treatment requiring extended period of post treatment analgesia. Conclusions: Electrochemotherapy is safe and effective treatment for cutaneous metastases. Appropriate patient selection for treatment, pre-emptive analgesia, post treatment support and follow up is essential in order to maximise the benefits and minimise potential side-effects particularly in extensive chest wall disease.
What is the impact of reduction mammoplasty for women undergoing breast-conserving surgery for breast cancer?
Authors: Lin Jolinta Yin-Chu , Bluebond-Langner Rachel , Choi Enid , Cheston Sally B. , Nichols Elizabeth M. , Cohen Randi Jill , Bentzen Soren , Drogula Cynthia , Kesmodel Susan , Bellavance Emily Catherine , Rosenblatt Paula , Tkaczuk Katherine Hanna , Slezak Sheri , Feigenberg Steven J.
Published: February 2017

49

Background: Reduction mammoplasty (RM) at time of breast conserving surgery (BCS) is an increasingly popular procedure that reduces redundant breast folds and skin toxicity from whole breast irradiation (WBI). However, the tissue manipulation may obscure the lumpectomy cavity (LC) and hinder the ability to deliver a radiation boost to the LC, potentially impacting local control. We studied the impact of RM on acute radiation side effects and the use of LC boost. Methods: From Jan 2012 to Dec 2014, 652 consecutive women with DCIS or Stage I-III invasive cancer were treated with curative intent BCS and WBI at an urban university and 2 community practices. We reviewed the charts on an IRB-approved study with the primary endpoint of ≥ grade 3 radiation dermatitis scored via the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. Secondary endpoint was the use of LC boost. Tested variables included age, race, body mass index, menopausal status, multi-focal disease, stage, tumor grade, receptor status, chemotherapy administered, specimen volume, 3D or intensity modulated radiation, fractionation, nodal irradiation, and planning treatment volume (PTV). Student's t-tests and Pearson's chi-square tests were utilized. Results: Forty-three (7%) of 652 patients underwent RM. Larger volumes of tissue were removed from the RM patients (median 366.5 g v 35.3 g, P= 0.0001). No grade 4 toxicities and few (2-3%) grade 3 toxicities were seen, P= 1.00. Narcotic use was similar (4-5%), P= 0.70. A LC boost was used in 476 (73%) patients; RM significantly decreased the use of a boost [16/43 (37%) v 460/609 (76%)], P= 0.0001. RM patients were more likely to have neoadjuvant chemotherapy, stage III or multi-focal disease, higher BMI, nodal irradiation, and conventional fractionation (P< 0.05). Subgroup analysis of the patients with available PTVs (67%) revealed similar volumes (P= 0.16). Conclusions: RM was associated with a decrease in the use of LC boost without significant differences in acute toxicities; however, the result is not surprising given that PTVs were similar. Further investigation is needed to better delineate LCs in patients undergoing RM to increase the use of LC boosts.
Breast cancer in young women: Indian scenario.
Authors: Selvakumar Veda Padma Priya , Garg Shubha , Kumar Rajeev
Published: February 2017

52

Background: Breast cancer in young women tends to be more advanced at presentation, more aggressive in nature with poorer survival. In this background we sought to study the clinicopathological profile of patients less than 40 years diagnosed with breast cancer at our institute. Methods: Out of the 1,330 patients who underwent surgery from December 2010 to December 2014 in the breast unit at our institute, 211 women were younger than 40. We retrospectively reviewed the clinic-pathological profile of these patients. SPSS 22 was used for statistical analysis and Kaplan Meier graphs plotted. Results: Mean age of patients was 35 years. The stage distribution was Stage 0: 2, Stage I: 9, Stage II: 81, Stage III: 95 and Stage 4: 2. 123 women underwent MRM and 85 breast conservation. On histopathological examination 202 were IDC, 1 ILC, 3 Mucinous Ca and 5 DCIS. 95(45 %) were Grade 3, 54 Grade 2 and 9 Grade 1. 55 patients were TNBC and 57 Her-2-neu positive. 57 underwent NACT while the rest underwent adjuvant chemotherapy, 170 received adjuvant radiation therapy and 122 adjuvant hormonal therapy. Overall survival is 98.9 % and DFS is 91.5 % at mean follow up of 17 months. Conclusions: In contrast to worldwide literature, around 15 % of women with breast cancer presenting to our institute were less than 40 years of age. They presented late with a higher stage, higher grade, and aggressive biology.
Preoperative breast MRI and MR-guided surgery of invasive breast cancers with and without DCIS components.
Authors: Kuhl Christiane K. , Bieling Heribert , Strobel Kevin , Wardelmann Eva , Kuhn Walter , Maass Nikolaus , Schrading Simone
Published: February 2017

58

Background: DCIS-components of invasive breast-cancers are a major cause for positive margins and reoperations in women undergoing breast-conserving-surgery. We investigated whether breast-MRI, through improved diagnosis of such DCIS-components, combined with MR-guided needle biopsy and pre-operative MR-guided lesion bracketing where appropriate, would help reduce reoperation-rates for invasive breast cancers. Our hypothesis was that with improved diagnosis of local disease extent through MRI and MR-guided surgery, reoperation rates should be low, and should be independent of the presence or absence of a DCIS-component. Methods: Prospective study in two academic breast-centers on consecutive patients with newly-diagnosed invasive breast-cancer. Women underwent breast-MRI in addition to conventional imaging (CI; digital-mammography/breast-ultrasound), and MR-guided needle-biopsy and preoperative MR-guided lesion bracketing where appropriate. Accuracy of breast-MRI for diagnosing DCIS-components was compared with that of CI, stratified by nuclear-grade and relative size of DCIS-components. Surgical outcomes (reoperation and mastectomy-rates) were recorded, stratified by presence or absence of DCIS-components. Results: 593 women were included. Surgical-pathology documented DCIS-components in 139/593 (23.4%) women. Sensitivity of MRI (84.9%) for demonstrating DCIS-components was significantly higher than that of CI (36.7%) (p < 0.0001); over half (51.1%) of DCIS-components were only detected by MRI. The sensitivity advantage of MRI over CI increased significantly with increasing relative size and nuclear-grade of the DCIS-component. Reoperation-rates were equivalent for women with vs. without DCIS-components (10.1% vs. 9.9%); mastectomy rates were 10.8% and 8.1%, respectively. Similar Positive-Predictive-Values were achieved with CI and MRI. Conclusions: Breast-MRI significantly improves depiction of DCIS-components of invasive breast-cancers prior to surgery. Use of breast-MRI and MR-guided surgery translates into low reoperation rates for women with operable invasive breast-cancer, which were similar for women with or without DCIS-components.
The use of one-step nucleic acid amplification (OSNA) and tumor-related factors in the axillary management of breast cancer: A predictive model.
Authors: Banerjee Shramana Mitul , Williams Norman R. , Davidson Timothy Ian , El-Sheikh Soha , Tran-Dang My-annh , Davison Stephen , Keshtgar Mohammed R.
Published: February 2017

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Background: Recent trends in surgical practice advocate selective use of axillary nodal clearance (ANC) following sentinel lymph node biopsy (SNB) in the treatment of breast cancer. We aimed to determine the effectiveness of one-step nucleic acid amplification (OSNA) using CK19 mRNA copy number and tumor-related factors in predicting non-sentinel axillary nodal involvement, in order to formulate local guidelines for ANC. Methods: Patients due to have SNB at our institution for invasive breast cancer as well as selected patients with high grade ductal carcinoma in situ with negative assessment of the axilla on pre-operative imaging were included. Alternate slices of each node were sent for assessment by either OSNA or Histopathology. Immediate ANC was performed if OSNA was positive. The CK19 mRNA copy number, the total tumor load (summation of m RNA copy number of positive nodes,TTL), the total nodal status at ANC and tumor characteristics including grade, tumor size and lymphovascular invasion (LVI) for each patient were determined. A model of risk probability was constructed using TTL and tumor related factors. Results: 664 nodes were examined from 425 patients who had SNB performed between 2011 and 2014. After excluding 8 patients who did not meet the study criteria, 648 nodes from 417 patients were included for analysis. The concordance between OSNA and histology was 91.4%; positive predictive value (PPV) and negative predictive value (NPV) was 77% and 97% respectively. Patients with TTL less than 1400 did not have additional non sentinel lymph node involvement. TTL (p<0.01), and presence of LVI (p<0.05) were predictive for additional nodal involvement. The risk model identified all patients with more than 2 positive nodes as requiring ANC. All patients with non-sentinel node metastases at ANC were selected. Conclusions: OSNA is a sensitive and reliable intraoperative method for the detection of sentinel node metastases. Our study has shown it can also be used to predict the presence of non-sentinel metastases. Patients deemed high risk may be offered immediate ANC while axillary surgery in other groups may be omitted or be decision-based on risk stratification.
Impact of selected tumor and patient characteristics on outcome of lymph node-positive breast cancer patients.
Authors: Nagy Ahmed Aly , Ibrahim Hager , Eid Lamiaa , Sayed Fatma , Kelany Mohamed Reda , Jomaa Mona kamal
Published: February 2017

66

Background: Axillary lymph node (ALN) involvement remains the most significant factor affecting long term survival in breast cancer (BC) patients, and the risk of treatment failure is increased with the higher the number of ALN involvement, The aim of this study was to determine the impact of tumor characteristics; tumor size and number of positive lymph nodes and, ER and HER-2, as well as patient characteristics on DFS of patients with Lymph node positive Breast Cancer Patients who received Adjuvant Treatment. Methods: We retrospectively reviewed data of 704 patients with BC and ALN involvement who received adjuvant treatment in the period between 2010 and 2012. DFS outcomes were estimated with the Kaplan-Meier method and compared using the log rank test to determine. The effect of prognostic factors on BC outcomes. Results: Median age was 50 years (SD±12.024, Range 21-88). About 83.7% of the tumors were IDC,. About 30.4%of the tumors were grade III. Median tumor size was 5 cm (SD± 1.3745, Range 1-7).Median number of positive axillary LN was 4 (SD± 4.987, Range 1-37). Regarding receptor expression; 21.2% were HER-2 +ve, 58.7% were ER +ve and about 30.4 were triple negative. Median DFS was 20 months (SD± 14.511, Range 1-60). Cox regression showed that age, positive ER status and more than 3 ALN involvement had a statistically significant impact on DFS ( p<0.001 for all ), however, Tumor size, HER-2 overexpression, patient menstrual status had no significant effect. ER positive age >50 years was associated with prolonged DFS of 23 months (95%CI=20.641-25.359) versus 19 months (95% CI=17.598-20.402) for age≤50 years (p<0.001). ER positive status was associated with prolonged DFS of 22 months (95%CI=20.290-23.710) versus 17 months (95% CI=14.049-19.951) for ER negative (p<0.001).The group of patients with ≤3 positive dissected LN was associated with statistically significant prolonged DFS of 25 months (95%CI=22.286-27.714) versus 15 months (95%CI = 12.353-17.647) for patients with>3 positive dissected LN (p<0.001). Conclusions: These study indicate that the age, ER status and more than 3 ALN involvement have impact on DFS in Lymph node positive Breast Cancer Patients.
Feasibility of a breast health educational program to increase breast cancer awareness among adolescents and their female relatives in low-income communities.
Authors: Soto Perez De Celis Enrique , Smith David D. , Baltazar-Avalos Edgar , Hurria Arti , Reyes-Bautista Martin A , Gitler-Weingarten Rina , Pavas-Vivas Alba M , Rojo-Castillo Patricia , Sirota-Toporek Max , Mohar Alejandro , Ayala-Gonzalez Mayte , Chaveste-Ramos Viridiana , Cosme-Gonzalez Brenda , Gallegos-Quintana Sofia N , Martinez-Aviles Ana FS , Melendez-Rosas Julia A , Salazar-Moreno Andrea , Chavarri Guerra Yanin
Published: February 2017

76

Background: Delays in the diagnosis of breast cancer in developing countries are partially related to a lack of knowledge on breast health (BH), particularly in rural communities with poor access to education. We implemented a BH educational program for adolescents from a rural community in Mexico, aimed at increasing knowledge and promoting intergenerational transmission of information from adolescents to their female relatives. Here, we report the results of our feasibility aims, as well as the change in knowledge in the students after the intervention. Methods: In this pilot study, adolescents enrolled in a public rural Mexican middle school were invited to participate in the program. They received age-appropriate, culturally sensitive sessions from expert educators focused on transmitting BH knowledge in their household. Our primary outcome was satisfaction with the content, with 75% approval needed for the program to be considered acceptable. Pre and post true/false tests to evaluate the students’ knowledge were applied. Paired t-test was used to detect changes in knowledge. A p value of < 0.05 was considered significant. Acceptability of the program among the school teachers was assessed. Results: 238 students were invited to participate, of which 126 (53%) provided parental consent and completed the program. Median age was 13.5 years (12-16). 96% (n = 121) of the students considered the sessions very interesting and 99% (n = 124) thought they either learned “a lot” (66%; n = 83) or “some” (33%; n = 41). The pre- and post-test mean proportion of correct answers was 63% (12.5-100%, SD 0.2) and 89% (25-100%, SD 0.12) respectively. A statistically significant improvement in the proportion of correct answers was found for 5 out of 8 questions. 100% (n = 18) of the teachers thought the intervention was acceptable. Conclusions: Our results show that implementing a BH educational program for rural adolescents in low-income communities is feasible and acceptable, and that such a program can increase their knowledge on BH. Our next planned step is to assess intergenerational transmission of the information to the students’ female relatives.
Prognostic impact of tumor-infiltrating lymphocytes (TIL's) and stromal-infiltrating lymphocytes (SIL's) in triple-negative breast cancer.
Authors: Sherwell-Cabello Santiago , Maffuz-Aziz Antonio , Camacho-Ramírez Diego A , Bautista-Piña Verónica , Ríos-Luna Nina P , Labastida-Almendaro Sonia , Rodriguez-Cuevas Sergio
Published: February 2017

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Background: Immune response seems to improve outcome in women with Triple-Negative Breast Cancer (TNBC). Recent data suggests that the presence of Tumor-Infiltrating Lymphocytes is an independent factor associated with better prognosis. In this study, we evaluate the prognostic impact of both TIL´s and SIL´s in patients with TNBC. Methods: Data on women diagnosed with TNBC between 2005 and 2013, was collected by retrospectively reviewing at our institute. The rate of intratumoral and/or stromal lymphocytes was evaluated in all hematoxylin and eosin-stained histopathologic sections according to Denkert et al. The five-year disease-free survival (DFS) and overall survival (OS) were compared between groups with the presence or absence of TIL´s or SIL´s. Demographic and clinical characteristics were assessed, variables with a statistical significance between groups were analyzed in a multivariate analysis. Results: A total of 172 patients with TNBC treated at this institution were included with a mean age of 49.8 years. A complete absence of tumor lymphocytes was found in 88 patients while the presence of intratumoral, stromal or both was found in 84 (48.8%). A mean follow-up of 46.12 months showed significantly higher rates of both DFS and OS in women with SIL´s and TIL´s (p = 0.014 and 0.042 respectively) in locally advanced stages (LAS), regardless the rate of infiltrating lymphocytes found [Table 1]. SIL´s are correlated with a better prognosis compared with TIL´s (p = 0.028 and 0.091 respectively). Non-significant differences were found in early stages (p= 0.255). Conclusions: These results show that the presence of SIL´s or TIL´s are strongly associated with higher rates of DFS and OS in LAS, especially when SIL´s are found, suggesting that immunity seems to play a key role regarding the outcome in women with TNBC. Independent of the rate of lymphocytic infiltrate, its presence has a statistical significance. Because it is a feasible and inexpensive test that can be used as a prognostic predictor, we suggest assessing both SIL's and TIL's in histopathologic biopsies of patients with TNBC. [Table: see text]
Documenting the impact of alopecia in breast cancer: Assessing the performance of the alopecia patient assessment (APA) questionnaire.
Authors: Piault-Louis Elisabeth , Petersen Jennifer , Gable Jonathon , Hudgens Stacie
Published: February 2017

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Background: The APA questionnaire was developed to document the emotional and social burden of alopecia experienced by breast cancer patients undergoing therapy. Content, clarity, and relevance of the measure were assessed by patients undergoing chemotherapy; the instructions, recall and APA items were found to be clear and relevant (Mathias et al., 2013). The next phase consists of documenting the performance of the APA measure as an evaluative tool for use in clinical research. Methods: The APA was implemented in a US observational multicentre, prospective, longitudinal cohort of 497 patients with HER2+ metastatic breast cancer (SystHERs) with a mixed modality for data collection (first paper and then transition to ePRO). The APA was collected at baseline and every 90 (± 15) days. The psychometric analysis was adapted based on the study design and on the manifestation of alopecia (onset, duration) in this population. The select set of psychometric tests included quality and pattern of completion, construct validity and reliability. Results: Quality of completion as measured by correct scale use was 85.2% (compliance was 95.6%). Discrimination indices were above the 0.3 threshold for each item on the APA and ranged from 0.59 to 0.82 at baseline. The scale demonstrated good internal consistency as assessed by 0.88 Cronbach alpha. Weighted kappa agreement of 0.49 was observed between the APA and the ‘I am bothered by hair loss’ item (B5) of the Functional Assessment of Cancer Therapy-Breast (FACT-B) measure. Conclusions: The APA is a valid and reliable measure able to discriminate change in patients’ daily functioning resulting from an alopecia event related to treatment for breast cancer. Results support the use of the APA in clinical research to better characterize the impact of alopecia on patients’ lives.
A novel breast cancer screening platform: An epitope-based biomarker coupled to electrochemical sensor.
Authors: Paiva Maia Yara Cristina , Araújo Thaise Gonçalves , Franco Diego Leoni , Capparelli Fausto Emilio , Ribeiro Vanesssa Silva , Fujimura Patrícia Tieme , Calábria Luanda , Paiva Carlos Eduardo , Santos Donizeti Wilian , Franco Juliana Almeida , Madurro João Marcos , Brito-Madurro Ana Graci , Freitas Renata Nascimento , Goulart Luiz R.
Published: February 2017

9

Background: The subtractive proteomic selection technology called Phage Display (PD) has been extensively used by our group in the discovery of high affinity ligands to target tissues and molecules. We have selected specific ligands against IgG purified from BC tissues, which was successfully coupled to an electrochemical sensor to detect the tumor-specific immune response. Methods: After PD selections, all immunoreactive peptide ligands were further characterized by DNA sequencing, in vitro translated and submitted to bioinformatic analyses. Further validations were performed by ELISA. We then used one synthetic peptide (SF4) for the construction of an immunosensor, which was applied to patients and control samples for final validation. Electrochemical impedance spectroscopy (EIS) was performed. Results: We have selected the F4 peptide for final validation and sensor construction due to its capability of detecting IgG in the peripheral blood and the excellent ELISA ratio BC:BBD, discriminating more than 70% of BC patients. The synthetic peptide reached a good precision in BC diagnosis (68%), but surprisingly, the selected F4 clone presented the highest sensitivity and specificity, (77.8% and 85.7%, respectively), suggesting that it can be used as a diagnostic reagent for early BC screening prior to imaging and pathological analyses. The electrochemical sensor that was built with the epitope-based peptide discriminated all IgG from BC and healthy individuals. Results with the EIS sensor demonstrated that the presence of (SF4) peptide IgG generated higher resistivity (-Z ') compared to the system containing only the peptide or the control sera. This is justified by the fact that with the immobilized biological peptide layer was correctly conjugated with the IgG forming an antigen: antibody complex that led to an increased resistance to the charge transfer system, producing a decrease in electron transfer between the iron-coupled / ferricyanide redox and the electrode surface. Conclusions: An electrochemical sensor using an epitope-based biomarker was developed, which allows for the first time BC screening using a very simple platform that could be an important auxiliary tool to mammography imaging.
Retrospective review of symptoms and palliative care interventions in women with advanced cervical cancer.
Authors: Kim YuJung , Munsell Mark F. , Park Ji Chan , Meyer Larissa , Sun Charlotte C. , Brown Alaina J. , Bodurka Diane C. , Williams Janet L. , Chase Dana Meredith , Bruera Eduardo , Ramondetta Lois M.
Published: February 2017

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Background: Symptoms reported by women with cervical cancer (CCx) include pain, fatigue, lymphedema, sexual dysfunction, proctitis, cystitis, constipation and diarrhea. The objective of this study was to delineate and measure the symptom distress experienced by patients with advanced CCx at the time of palliative care (PC) referral. Methods: A total of 156 advanced CCx patients were referred to PC from 2010 to 2012. Of these, 88 patients had completed the Edmonton Symptom Assessment System (ESAS) and were included in the analysis. Descriptive statistics were used to summarize the data. Results: At the time of presentation mean age was 45 (25-76), 47% were Caucasian, 18% African American, and 33% Hispanic. Fifty-one percent were married; 64% had no advance directives; 75% had recurrent disease. Clinically significant symptoms (defined as ESAS scores ≥ 4) were pain (81%), anorexia (72%), a poor feeling of well-being (70%), fatigue (69%), and insomnia (54%). The chief complaint was pain in 94% of patients. According to the PC specialists’ assessment, pain (96%), emotional distress (77%), and constipation (50%) were predominant symptoms. Various palliative care interventions including opioids, laxatives, and expressive supportive counseling were provided. The median time from advanced cervical diagnosis to PC consultation was 6.0 months (95% CI 5.0-7.8) and the median survival after first PC visit was 4.8 months (95% CI 3.4-6.2). Clinically significant symptoms including nausea, depression, anxiety, and feeling of well-being showed significant improvements at follow-up visits. Conclusions: More than half of patients with advanced CCx were significantly burdened with pain, anorexia, poor feeling of well-being, fatigue, insomnia, and constipation at the time of PC referral. Clinically significant symptoms showed improvements at follow-up visits. In patients with significant symptom distress, early PC involvement may be important to improve quality of life.
Increasing patients' preferences for palliative care through the dissemination of palliative care research: Impact of socioeconomic status, geography, and depression severity.
Authors: Hoerger Michael , Barkan Tessa , Perry Laura , Voorhees Sara , Rochefort Catherine , Seibert Katherine
Published: February 2017

109

Background: Approximately 4 out of 5 Americans are unfamiliar with palliative care, a significant barrier to utilization. Accordingly, providing patients with knowledge could empower them to seek palliative care. As a pilot investigation, the EMPOWER Study examined the impact of a psychoeducational intervention on patients’ preferences for palliative care. Methods: Participants were 581 patients with heterogeneous cancer diagnoses recruited through the NIH-sponsored ResearchMatch program. The study used a between-group pre-post design, completed in a single session via the Internet. Random assignment determined whether participants received psychoeducational information summarizing the results of the Temel et al. (2010) palliative care article, using a plain-language and graphical format. Participants completed measures of their health history, demographics, socioeconomic status (education level, financial strain, subjective financial standing), and depression symptom severity and completed a pre-post measure of preferences for palliative care. Results: Relative to controls, participants receiving the intervention experienced an increase in preferences for palliative care (p < .0001). The standardized mean difference in pre-post change was greater than a standard deviation in magnitude (Cohen’s d = 1.03), a “large” effect size by conventional standards. The intervention showed comparable effects across key patient subgroups, including patients of low socioeconomic status, patients living in low-access states, and patients with greater depression symptom severity. Conclusions: Providing patients with knowledge of recent research findings increased preferences for palliative cancer care. The next step is to develop psychoeducational interventions that are grounded in stakeholder input and incorporate a broader evidence base. This line of research has implications for empowering patients and their families to seek care that can improve quality of life.
Variability of physician perspectives toward advance care planning for patients with incurable cancer and congestive heart failure.
Authors: Chandar Manisha , Brockstein Bruce , Zunamon Alan , Silverman Irwin , Dlouhy Sarah , Ashlevitz Kathryn , Tabachow Cory , Ewigman Bernard , Mazzone Theodore , Obel Jennifer Carrie
Published: February 2017

12

Background: Advance Care Planning (ACP) discussions afford patients and physicians a chance to better understand patients’ values and wishes regarding end-of-life care; however these conversations typically take place late in the course of a disease, or not at all. The goal of this study was to understand attitudes of oncologists, cardiologists, and primary care physicians (PCPs) towards ACP. We also aimed to identify persistent barriers to timely ACP discussion following a quality improvement initiative at our health system aimed at improving ACP completion rate. Methods: A 23-question cross-sectional online survey was created and distributed to cardiologists, oncologists, primary care physicians and cardiology and oncology support staff at the NorthShore University Health System (NorthShore) from February-March 2015. A total of 117 individuals (46% of distributed) completed the surveys. The results were compiled using an online survey analysis tool. Results: Only 15% of cardiologists felt it was their responsibility to conduct ACP with their congestive heart failure (CHF) patients. In contrast, 68% of oncologists accepted responsibility for ACP in incurable cancer patients. Sixty-eight percent of PCPs felt personally responsible for conducting ACP discussions with CHF patients, while only 34% felt the same about cancer patients. Documentation of ACP in the electronic health record (EHR) was inconsistent among specialties. Among all surveyed specialties, lack of time was the major barrier limiting ACP discussion. Perceived patient discomfort and discomfort of the patient’s family towards these discussions were also significant reported barriers. Conclusions: Attitudes toward ACP implementation vary considerably by medical specialty and medical condition, with oncologists in this study feeling more personal responsibility for carrying out these discussions with cancer patients than cardiologists with their heart failure patients. Robust implementation of ACP across the spectrum of medical illnesses is likely to require a true collaboration between office-based PCPs and specialists in both the inpatient and ambulatory settings.
Barriers to traditional palliative care for stage IV breast cancer patients, 2003-2012.
Authors: Shi Runhua , Marion Jay M. , Shi Zhenzhen , Diaz Richie R , Mills Glenn Morris
Published: February 2017

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Background: Multiple factors may impact ability of patients with Stage IV breast cancer to access traditional palliative care (PC), which centers on disease-altering procedures such as surgery, radiation therapy, and chemotherapy. To further investigate barriers to accessing PC, the National Cancer Data Base data from 2003-2012 was analyzed. Methods: Data was analyzed from 55,490 patients diagnosed with Stage IV breast cancer registered in the National Cancer Data Base. The outcome variable was patient use of PC. The predictor variables included sex, age, race, Charlson Comorbidity index, insurance status, income, education, year diagnosed, distance travelled, facility type, diagnosing/treating facility, and diagnosis to treatment interval. Univariate analysis was used to determine the prevalence of palliative care according to predictor variables. Multivariate Logistic regression was used to investigate the effect of each predictor variable on patient use of PC while adjusting for all other predictive factors. Results: Of the 55,490 Stage IV breast cancer patients analyzed, 17.38% received palliative care. Radiation therapy (8.76%) and chemotherapy, hormone, and other systemic treatments (4.51%) contributed to the bulk of PC. In multivariate analysis, after adjustment for all other predictor variables, race, income, education, distance travelled, and diagnosis to treatment interval were each shown to significantly predict use of PC. Black and Asian patients were 11.4% and 26.1% less likely to use PC than their white peers. Lower zipcode income, higher zipcode education, and shorter distance travelled were predictors of increased PC use. Shorter diagnosis to treatment interval was a predictor of increased PC use; compared to patients with a 31+ day interval, those with a 0-7 day interval were 67.71% more likely to receive PC and 8-31 day interval, 37%. Conclusions: Using univariate and multivariate analysis, we identified factors that may act as barriers to access traditional palliative care for patients diagnosed with Stage IV breast cancer. We observed that race, income, education, distance travelled, and diagnosis to treatment interval significantly predicted the use of palliative care.
Risk factor assessment of hospice patients who are readmitted within 7 days of acute care hospital discharge.
Authors: Wilson Anthony E , Martins-Welch Diana , Earle Bridget , Kozikowski Andrzej , Attivissimo Lori , Rosen Lisa M , Pekmezaris Renee
Published: February 2017

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Background: Although 20% of adults 65 and older are re-hospitalized within 30 days of discharge, there is a dearth of research investigating readmission of patients discharged to hospice and the predictors of the readmissions. The study aim was to identify risk factors for hospital readmission within 7 days of discharge to home hospice. Methods: This was a retrospective case control study with cases being patients discharged to home hospice that were readmitted to the hospital within 7 days. Controls were patients discharged to home hospice and not readmitted to the hospital within 7 days. Descriptive statistics were used to describe demographic and clinical characteristics. The chi-square or Fisher’s Exact test were used to compare categorical predictors between cases and controls. The two-sample t-test or the Mann-Whitney test were used to compare continuous predictors between cases and controls. Results: There were 163 subjects; 46 cases (28.22%) and 117 controls (71.78%). The most frequent hospital diagnosis was cancer (56.4%). There was a significant association between 7-day readmission (i.e., case) and age (P < 0.0041), race (P < 0.0008), language (P < 0.0007) and insurance (P < 0.0001). Specifically, cases were significantly younger than controls (69.5 vs. 77.0). Cases were more likely to be Hispanic (15.2 vs. 5.1), Asian (15.2 vs. 5.1) and other (13.0 vs. 2.6) when compared to controls. Cases were more likely to speak Spanish (13.3 vs. 3.5) or other (20.0 vs. 5.3) and less likely to speak English (66.7 vs. 91.2). Cases were less likely to have Medicare (8.7 vs. 82.9) and more likely to have Medicaid (32.6 vs. 4.3), private insurance (13.0 vs. 10.3) or other form of insurance including dual eligibility (45.7 vs. 2.6). Gender, marital status, religion, hospital diagnosis, discharge day, family support at home, symptoms and emergency contact relationship were not significantly association with 7-day readmission. Conclusions: Our data highlights four risk factors, namely age, race, language and insurance status as factors predicting readmission within seven days of acute care hospital discharge. Further study of these predictors may identify opportunities for interventions to obviate these readmissions.
Effect of palliative doctor in medical oncology team on patient outcomes.
Authors: Xu Zhi Zhen , Neo Patricia , Peh Tan Ying , Yee Alethea , Zhu Xia , Yang Grace Meijuan
Published: February 2017

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Background: Advanced cancer patients have a high symptom burden and not infrequently have unplanned hospital admissions. In our institution, PM services are provided via a separate consult team rather than an integrated palliative oncology team. Sometimes, PM doctors join the oncology team as integrated members for a few months each as part of their PM fellowship training program. This study aims to explore the effect of this PM doctor. Methods: Patients admitted under the lung and gastrointestinal (GI) oncology teams from June 2013 to June 2014 were studied as this cohort of patients had a higher symptom burden and were more likely to benefit from PM input. The following information for each month was obtained from the computer system: hospital length of stay, formal referrals for a PM consult, 30-day, 60-day and 90-day mortality, and place of death. 2-sample T test was used to compare outcomes when there was a PM doctor in the oncology team for at least half of the month versus when there was not. Results: See table below. The presence of a PM doctor reduced the monthly percentage of formal referrals for PM consults but did not have clinically significant effects on other outcomes. Conclusions: PM doctors were there to learn oncology rather than provide a PM service. However, a reduction of PM referrals suggests that they were still able to meet some of the PM needs of the patients admitted. A new model of PM service provision whereby a PM healthcare professional is integrated within the oncology team warrants further study. [Table: see text]
Is there an unmet need for palliative care in cancer patients admitted to hospital?
Authors: Zhu Xia , Neo Patricia , Peh Tan Ying , Xu Zhi Zhen , Yee Alethea , Yang Grace Meijuan
Published: February 2017

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Background: Cancer patients who are admitted to hospital often have symptom problems and progressive functional decline, and may benefit from palliative care (PC) input. The aim of this study was to determine the profile of patients admitted under Lung and Gastrointestinal (GI) oncology teams (as their cohorts of admitted patients probably have more symptom problems) and whether they are being referred for PC input. Methods: Patients admitted from 1 March 2015 to 31 March 2015 were included. The following were recorded: primary site of tumor and whether it was metastatic, whether the admission was planned or unplanned, referral for PC input, outcome of admission and unplanned readmission within 7 days and 30 days. Results: See table below. Conclusions: Although 84% of patient admissions had metastatic cancer and 82% were unplanned admissions, only 21% were referred for PC input. This represents a missed opportunity for PC input, which has been shown to improve outcomes in patients with advanced cancer. However, if all advanced cancer patients who had an unplanned hospital admission were referred for PC, there would be a large increase from the current workload of the PC team. Hence, there is a need to pilot a novel model of PC provision, perhaps one in which a PC healthcare professional joins the oncology team to provide integrated palliative oncology care. [Table: see text]
Outpatient palliative care encounters in stage IV lung cancer care: An institutional review.
Authors: Rizk Sophia , Prsic Elizabeth Horn , Rafelson William , Reagan John Leonard , Taber Angela Marie
Published: February 2017

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Background: Palliative Care (PC) is becoming increasingly integrated into standard oncologic care (SC). Previous research suggests that patients receiving PC report better quality of life, and may have prolonged survival. This study evaluates the effect of PC integration in patients diagnosed with stage IV non-small cell lung cancer (NSCLC) at a single institution. Methods: All patients diagnosed with Stage IV NSCLC between January 2010 and January 2013 were considered for inclusion and retrospective analysis of their care. Charts were reviewed to identify patients who received outpatient PC with a licensed PC physician in addition to SC. There were no guidelines regarding the nature of the PC intervention. Retrospective analyses of multiple factors were assessed, including: receipt of chemotherapy and/or radiotherapy, utilization of emergency and sick visits, frequency and timing of hospice referral, and duration of hospice utilization. Overall survival was also assessed. Results: 136 patients fulfilled study inclusion criteria. 29 patients received PC in addition to SC, and 107 received SC alone. No statistically significant difference was noted between the groups with respect to age, sex, lines of chemotherapy administered, number of emergency department visits, or number of clinic sick visits. Hospice was offered more frequently in the PC group; however, there was no difference in the amount of time spent on hospice, and no difference in overall survival. There was a trend towards longer survival in the PC group (220 days vs. 254 days). Patients seen in a multidisciplinary clinic were significantly more likely to receive a PC evaluation (RR 1.28 CI 1.073-1.52, p < 0.006). Conclusions: This retrospective study examines how PC is integrated in actual clinical models. Multidisciplinary clinic patients were more likely to receive PC after controlling for comorbidities. There was no significant difference between PC and SC group outcomes. Although this study is small, it demonstrates common practice patterns, and identifies the need to identify the components of the PC encounter that are important in order to maximize the potential benefits of PC interventions.
Timeliness of end-of-life (EOL) discussions for blood cancers: A national survey of hematologic oncologists.
Authors: Odejide Oreofe Olukemi , Cronin Angel , Condron Nolan , Earle Craig , Wolfe Joanne , Abel Gregory Alan
Published: February 2017

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Background: Although timely EOL discussions have been shown to positively impact EOL care for patients with advanced solid tumors, little is known about EOL discussions for patients with blood cancers. Methods: In 2014, we mailed a 30-item survey to a national sample of hematologic oncologists randomly selected from the American Society of Hematology clinical directory. The survey was developed through focus groups (n=20) and cognitive debriefing (n=5) with hematologic oncologists. We report preliminary data regarding timing of EOL discussions. Results: We received 349 surveys from 48 states (response rate: 57.3%). Median age was 52 years, median time in practice was 25 years, and 43% practiced primarily in tertiary centers. Of all respondents, 56% reported that EOL discussions with blood cancer patients typically occur “too late.” The great majority also reported conducting initialdiscussions regarding resuscitation status, desire for hospice care, and preferred site of death at times other than periods of disease stability (Table). In multivariable analysis adjusting for gender, years in practice, and self-reported confidence leading EOL discussions, respondents practicing in tertiary centers were more likely to report that such discussions occur “too late” (OR=1.91, 95% CI [1.22, 2.98]). Similarly, hematologic oncologists practicing in tertiary centers were less likely to report conducting timely initial resuscitation status discussions (before acute hospitalization or before death clearly imminent, OR=0.52, 95% CI [0.33, 0.82]). Conclusions: The majority of hematologic oncologists in our large national cohort reported late EOL discussions. Moreover, clinicians in tertiary centers were more likely to report late discussions, even when prompted about specific EOL topics. Our data suggest that physician-focused interventions to improve timing of EOL discussions for blood cancers should target those practicing in tertiary centers. [Table: see text]
Overcoming barriers to hospice care for children with cancer: Promoting active participation of the oncology team.
Authors: Fernandez Karen S. , Rogers Diane , Look Leigh M. , Antony Reuben
Published: February 2017

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Background: The concept of pediatric hospice care is a natural progression of the hospice philosophy as it has been applied to adults, although, there are unique challenges presented by children. At our institution hospice service for children are offered by the adult team. We evaluated the number of children with cancer eligible for hospice between July 2009 and May 2015 and also explored the barriers that prevented hospice enrollment and the experiences of families, and hospice staff. Methods: Retrospective Review, Programmatic Initiative. Results: Thirty-two children diagnosed with cancer died in a 6 year period. Diagnosis breakdown was: Solid tumors 17/32 (53%), brain tumors 8/32 (25%), leukemia/lymphoma 6/32 (19%), 1 rare hematology condition. Twenty-one patients (65%) were 0 – 9.99 years and 11(35%) between 10 – 19.99 years. Fifteen patients (47%) were enrolled in hospice and all died at home except one. 18/32 (56%) children died in the hospital, of those 10/18 (55%) their parents chose the hospital as the site for their children passing, 6/18 (33%) died from an unexpected acute episode that resulted in death, and 2/18 (11%) patients had an acute episode that lead to un-planned patient hospitalization. The identified barriers to establishing and delivering hospice care were: a) family unwillingness to work with the hospice team b) family desire to have the patient die in the hospital c) hospice services not available in the patient’s residential area and, d) low level of comfort in the care of young children on the part of the hospice staff. Families expressed mixed feelings regarding hospice services. Conclusions: Hospice services for children with cancer are underutilized. There are family, institutional and community barriers to hospice enrolment for children with cancer. The great majority of patients still die in the hospital. We propose to improve our regional pediatric hospice service by strengthening collaboration between pediatric oncology, palliative care and hospice to better serve children with cancer at the end of life with a programmatic initiative involving the oncology team. We aim to evaluate the impact of this initiative on families, hospice staff and the oncology team.