bluuebunny/crossref_metadata_2025 huggingface dataset:
Correlates of and interrelationships among social stressors, relationship quality, and family functioning among informal cancer caregivers.
Authors: Kent Erin E. , Litzelman Kristin , Rowland Julia Howe
Published: February 2017

230

Background: Informal/family caregivers play a critical role in supporting cancer patients and are often an important part of the palliative care team. To better understand how informal caregivers are influenced by their role and inform future interventions, this study sought to evaluate the distribution and correlates of social and family factors among caregivers of cancer patients. Methods: This cross-sectional study used data from the Cancer Care Outcomes Research & Surveillance Consortium (CanCORS). Lung and colorectal cancer patients nominated an informal caregiver to participate in a caregiving survey. Caregivers reported their sociodemographic and caregiving characteristics, social stress, relationship quality with the patient, and family functioning. Descriptive statistics were used to assess the distribution of caregivers’ social factors. Multivariable linear regressions were used to examine the independent correlates of each social factor. Results: Most caregivers reported low-to-moderate levels of social stress and good relationship quality and family functioning. In multivariable analyses older age was associated with lower social stress and better family functioning, but worse relationship quality, with effect sizes (Cohen’s D) up to 0.40 (p < 0.05). Caring for a female patient was associated with lower social stress and better relationship quality, but worse family functioning (effect sizes up to 0.16, p < 0.05). Few caregiving characteristics were associated with social stress, while several were significant independent correlates of relationship quality. Finally, social factors were important independent correlates of one another. Conclusions: The results highlight the importance of personal and caregiving-related characteristics and the broader family context to social factors. As social factors may play an important role in the health, quality of life, and caregiving efficacy of informal caregivers, future work is needed to better understand these pathways and assess whether interventions targeting social factors can improve caregiver well-being, thereby potentially improving patient-centered palliative care.
Developing a conceptual framework of optimal spiritual care: Clergy perspectives.
Authors: LeBaron Virginia T. , Quinones Rebecca , Nibecker Callie , White-Hammond Gloria , Smith Patrick T. , Balboni Tracy A. , Balboni Michael
Published: February 2017

234

Background: An intriguing finding from previous research is that spiritual support by clergy led to more aggressive care at the end-of-life (EOL), particularly for Black and Latino patients. A better understanding of this phenomenon is critical as aggressive EOL care results in poorer patient and caregiver quality of life, and can significantly impact the death experience. Methods: This was a qualitative, descriptive study. The purpose was to develop a conceptual framework regarding clergy perspectives of optimal spiritual care provision to inform an EOL educational curriculum for clergy. Clergy from varying spiritual backgrounds, geographical locations in the U.S., and race/ethnicities were recruited. Semi-structured interview guides were developed by an interdisciplinary panel of medical educators and religious experts. Interviews were audio-taped, transcribed verbatim, and de-identified. Following principles of grounded theory, a final set of themes and sub-themes were identified through an iterative process of constant comparison. Results: A total of 35 clergy participated in one-on-one interviews (N = 14) and two focus groups. 43% of clergy were Black/African-American, 50% Caucasian and 7% Asian. 7% self-identified as Latino/Hispanic; most reported affiliation with a Christian denomination (96%). Primary themes included Patient Spiritual Struggles, Who Clergy Are (‘Being’), What Clergy Do (‘Doing’) and What Clergy Believe (‘Believing’). Spiritual struggles focused on existential questions, practical questions and difficult emotions. ‘Being” was supported by subthemes related to various manifestations of Presence; “Doing” by subthemes of religious activities, pastoral support, meeting the needs of patient/families, and mistakes to avoid; “Believing” by subthemes of having a relationship with God, virtues, and eternal life. Conclusions: Understanding clergy perspectives regarding optimal spiritual care provision is crucial to improve EOL care, especially for patient populations highly engaged with faith communities. This conceptual framework can help inform the design of educational EOL care initiatives for clergy and foster productive dialogue among clergy, clinicians, and patients.
Effect of a spiritual care training program on patient quality of life and spiritual well-being.
Authors: Yang Grace Meijuan , Tan Yung Ying , Cheung Yin Bun , Dignadice Dennis , Lim Amy , Lye Weng Kit , Ng Lola , Peh Tan Ying , Ramaswamy Akhileswaran , Suppiah Sarasvathy , Tan Angela , Tan Yee Pin , Xu Zhi Zhen , Yee Alethea , Zhu Xia , Neo Patricia
Published: February 2017

235

Background: Spiritual care (SC) is a vital part of palliative care (PC) but its provision is still not routine. We studied the effect of a SC training program for staff on patient quality of life (QOL) and spiritual wellbeing (SPS), as measured by the Functional Assessment of Chronic Illness Therapy – Spiritual Well-Being (FACIT-Sp). Methods: This study was conducted at two sites: a PC consultative service in an acute hospital and a home PC service. The program comprised a 30 min training session for nurses and doctors on using the FICA tool for spiritual assessment and subsequent referral to a medical social worker (MSW) if needed, and a 60min training session with the MSWs on how to manage spiritual problems. A prospective cluster-controlled trial was done across 7 clusters. FACIT-Sp comprises 27 items for QOL (FACT-G) in the 4 domains and 12 items for SPS. This was administered at T1: upon referral to the palliative care service and T2: after 3 clinical visits by the PC team (doctor, nurse or MSW visits). Results: QOL data from 142 participants (69 intervention and 73 control) were analyzed. There appeared to be some benefit of the program on all domains of QOL as well as SPS, although only the FACT-G score achieved statistical significance. After further statistical adjustment for scores at T1 (to account for any regression to the mean), FACT-G score remained practically significant (p value 0.076). Conclusions: A brief SC training program for staff (30 min for nurses and doctors, 60 min for MSWs) appeared to result in some improved QOL and SPS for patients. However, a larger sample size will be needed to estimate the degree of benefit more accurately. [Table: see text]
Patient and provider perceptions about exercise in cancer care, excluding breast: Are we on the same page?
Authors: Smaradottir Agnes , Oettel Kurt R. , Smith Angela , Borgert Andrew
Published: February 2017

238

Background: Cancer organizations recommend physical activity as part of therapy to aid in symptom management, reduce recurrence and improve overall quality of life. What the optimal exercise program should look like and what stakeholder barriers exist are unclear. Methods: We convened three focus groups, one with metastatic patients, one with non-metastatic patients, one with the providers in the Cancer Center and conducted individual interviews at Gundersen Health System in La Crosse, Wisconsin. The constant comparative method was used to identify themes about exercise as part of cancer treatment. Results: No statistical differences in demographic characteristics exist between metastatic (N = 9) and non-metastatic (N = 11) patients. Impacts of exercise on cancer, who should instruct patients about exercise and how/where the exercise should take place emerged as the main themes. Discordance between patients and providers (N = 10) was identified in these areas. Patients felt that exercise during treatment provided intrinsic value (“Exercise mentally is important”) whereas providers connect exercise to positive disease outcome (“There are decreased recurrence rates for multiple different malignancies that have been proven in large studies”). Patients resoundingly expressed a desire to receive instructions for exercise from their oncologist (“I rely a lot on my oncologist...they are tuned into you”). Providers expressed a desire for a referral process to a cancer trained physical therapist or trainer who would guide patients through an exercise program (“to have assistance from someone who is trained… would be really beneficial”). Conclusions: Providers recognize the importance of exercise as part of a cancer treatment plan, yet they agree that time constraints associated with a busy practice impacts the priority of exercise instructions. Bridging the gap we identified between patient and providers’ perceptions has potential for cancer care across the nation. We plan to further study the discord after designing standard exercise recommendations at varied levels of intensity through collaboration with oncology providers, physical therapy and Livestrong personnel utilizing venues in our region.
Fatigue in long-term non-Hodgkin lymphoma survivors.
Authors: Hudson Kathryn Elizabeth , Benecha Habtamu Kassa , Houck Kevin Leo , LeBlanc Thomas William , Abernethy Amy P , Zimmerman Sheryl , Ganz Patricia A. , Smith Sophia Kustas
Published: February 2017

239

Background: Fatigue is a common and distressing effect of cancer and its treatment, potentially affecting quality of life (QOL) for years after treatment. However, the prevalence and persistence of fatigue among long-term survivors of non-Hodgkin lymphoma (NHL) remains unknown. We aimed to identify demographic, clinical, and psychosocial risk factors for persistent fatigue in this population. Methods: In 2010, surveys were mailed to 682 NHL survivors who participated in a study 5 years earlier; respondents were, on average, 10.4 years post diagnosis. Standardized measures of QOL, symptoms, medical history, and demographic variables were reported at both time points. We defined significant fatigue conservatively as 0.5 standard deviations below the SF-36 scale’s cutoff for fatigue, and we defined persistent fatigue as significant fatigue at both time points. Chi-square, t-tests, and logistic regression were used to determine risk factors and predictors for persistent fatigue. Results: 30.8% (n = 172) and 33.0% (n = 186) of patients reported significant fatigue at time point 1 and 2, respectively; 20% of patients had persistent fatigue. Patients with persistent fatigue were more likely to report: female gender, income < $30,000, less than college education, less exercise, active disease, chemotherapy, at least one recurrence of their disease, less social support, an average of 3.8 more comorbidities, and significantly more posttraumatic stress than those without persistent fatigue (all p < .05). Logistic regression showed that education less than college, more comorbidities, less exercise, and more posttraumatic stress were independent predictors of persistent fatigue (all p < .05). Conclusions: Fatigue plagues one-third of NHL survivors and persists in one-fifth of this population even years after diagnosis. These findings could inform clinical practice in NHL survivorship and highlight targets for intervention.
Assessing associations between symptoms and survivorship care plans among long-term cancer survivors.
Authors: Tisnado Diana , Steers Neil , Peirce Katelynn , Walling Anne M.
Published: February 2017

246

Background: Nearly 14 million Americans are cancer survivors, and numbers are increasing. Common long-term and late effects reported by survivors include anxiety, depression, fatigue, pain, and others. In order to address potential long-term and late effects of cancer and its treatment, the IOM recommends that patients receive a Survivorship Care Plan (SCP), a record of care received and important disease characteristics and a follow-up care plan incorporating available evidence-based standards of care. Our aims were to assess prevalence of self-reported moderate-severe symptoms and worry, and test for associations with SCP receipt. Methods: We used data from CanCORS II, a national study of lung and colorectal cancer patients. Long term survivors were diagnosed in 2004, and showed no sign of disease seven years post-diagnosis. We included 888 lung and colorectal cancer survivor respondents to the CanCORS II Long Term Survivor Survey. We examined moderate-severe pain (3, 4, or 5 on the SF-36 pain interference item), fatigue (less than 40 on the SF-36 vitality score), depressive symptoms ( > 6 on CESD-8), and worry about recurrence. SCP receipt was defined as receipt of a treatment summary, follow-up care plan, or both. Multivariable logistic regression was used to test for associations between SCP and symptoms and worry. Results: In all, 27% of survivors had 0, and 26% had both SCP components. Moderate-severe pain was reported by 32% of colorectal and 42% of lung cancer survivors, and fatigue by 15% of colorectal and 30% of lung cancer survivors. Moderate-severe depressive symptoms were reported by 12% of colorectal cancer and 16% of lung cancer survivors. Less than ¼ (23%) reported worry about recurrence sometimes, often or always. In analyses adjusting for demographics and health status, receipt of both SCP components was associated with lower odds of moderate-severe pain (OR = 0.78, p = 0.004), fatigue OR = 0.42, p = 0.006), and depressive symptoms (OR = 0.48, p = 0.03). Conclusions: Receipt of a complete SCP was associated with lower odds of moderate-severe pain, fatigue, and depressive symptoms. We found no association with worry. However, only 26% of survivors reported receipt of both SCP components as recommended.
Using standardized patients to improve delivery of bad news by pediatric hematology-oncology fellows.
Authors: Brackett Julienne , Frugé Ernest , Lorin Martin
Published: February 2017

29

Background: First-year pediatric hematology-oncology fellows frequently must deliver difficult news to patients and families, possibly with little prior experience. Training in this area is often via didactic lectures and by “trial and error”. This can lead to significant discomfort on the part of fellows and potentially increased distress on the part of families if information is poorly communicated. Standardized patient (SP) encounters provide a safe environment for fellows to practice effective and compassionate communication skills. SPs can provide feedback to the fellows that may not otherwise be available from patients, families or peers. Methods: During the 4 hour course, fellows receive didactic sessions on delivery of bad news, disclosure of medical errors, and discussion of prognosis and goals of care. Half of the fellows receive the didactic sessions, while the other half participate in the SP cases involving 7-10 minute encounters followed by 10-15 minute confidential debriefings including the fellow, SP and a faculty member. Three cases are completed by each fellow: new diagnosis of an incurable brain tumor, tumor progression and goals of care discussion regarding the same patient 6 months later, and disclosure of a chemotherapy error. At the end, fellows complete an evaluation of the course and their perceived post-course skills. Results: Fellows in the first course (n = 8) strongly agreed that the course improved their ability to deliver bad news (mean = 5 on 5 point scale), was an appropriate method for this material (mean = 4.6) and that the confidential debriefing was useful without being stressful (mean = 4.7). Most comments supported the utility of receiving immediate feedback from the SPs and faculty. The didactic sessions were listed as the least helpful part of the course. Conclusions: Simulated encounters with immediate feedback from SPs and faculty can improve perceived competence in the delivery of bad news. Like many adult learners, course participants did not find the didactic sessions to be as helpful as interactive experiences. Follow-up surveys after the fellows complete the first year of training will further assess the utility of this instructional method.
“Months, not years”: Impact of clinical discussions of advanced cancer life-expectancy on patient illness understanding.
Authors: Epstein Andrew S. , Prigerson Holly Gwen , Saltz Leonard , O'Reilly Eileen Mary , Shah Manish A. , Maciejewski Paul K
Published: February 2017

30

Background: Patients’ understanding of their illness often guides best practice, and this is no less true at the end of life. Data showing the influence of patients’ acknowledgment of prognostic discussions on the accuracy of patients’ illness understanding could inform the debate regarding how to engage in these difficult discussions. Methods: To evaluate the effects of recent and past oncologist-patient discussions about prognosis/life-expectancy (P/LE) on changes in advanced cancer patents’ illness understanding (acknowledgement of their illness as 1. terminal; 2. incurable; 3. advance staged; and 4. associated with an estimated life-expectancy in months, not years), 208 patients (with advanced lung or upper gastrointestinal cancers that progressed on 1 chemotherapy regimen, or advanced colorectal cancers that progressed on 2) from Coping with Cancer II, a prospective observational cohort study, were interviewed before and after a visit with their oncologists who discussed scan results regarding potential additional progression. Results: Median time between pre- and post-scan interviews was 38 days. Controlling for potential confounds (i.e., patients’ race) and adjusting for patients’ pre-scan illness understanding, patients who acknowledged ever having discussions of P/LE with their oncologists were more likely to recognize that their disease was incurable (Adjusted Odds Ratio [AOR] = 2.97, p = 0.009) than those who did not. Compared to patients who denied ever having a discussion of P/LE, those who reported having both recent and past discussions of P/LE were more likely to recognize that their disease was at an advanced stage (AOR = 4.88, p = 0.012), and those who reported having only recent discussions, or both recent and past discussions, of P/LE were more likely to estimate their life-expectancy in terms of months as opposed to years (AOR = 10.1, p = 0.050, and AOR = 17.5, p = 0.006, respectively). Conclusions: Advanced cancer patients who acknowledge having discussions of P/LE with their oncologists have a better understanding of the terminal nature of their illnesses as compared to those who do not, and thus may be better prepared to make informed end-of-life care decisions.
Discussing goals of care preoperatively in high-risk oncologic surgery.
Authors: McGreevy Chris , Kunac Anastasia , Chokshi Ravi , Smith Janet Harris , Mazza Debra , Mosenthal Anne C
Published: February 2017

38

Background: Major oncologic surgery has a high incidence of perioperative morbidity. Despite these risks, most surgeons do not discuss goals of care prior to surgery. This study assessed the feasibility of a preoperative goals of care discussion for high risk oncologic surgery. Methods: Observational study of patients undergoing high risk surgery. Prior to surgery, patients were referred for consultation with a surgeon certified in both Palliative and Critical Care. Consultations followed a semi-structured template (table). Patient and conversation outcomes were assessed, and qualitative analysis of consult notes was performed to identify themes. Results: Twelve patients were approached and 11 participated. Mean time between consultation and surgery was 7 days (1-36). All patients named a health care proxy and expressed goals of care. Most (8/11) specified their preferences for life support. Themes included hope –surgery will return them to independence/home; fear – pain, anxiety; and faith–“it is up to God” as reason for not discussing suboptimal surgical outcomes. One patient declined surgery after discussion and transitioned to hospice. Ten survived to discharge: 6 to home (2 with hospice), 4 to rehab. Conclusions: Preoperative goals of care discussions are feasible for high risk oncologic surgery patients. Eliciting goals of care helped clarify wishes for life sustaining therapy. Goals of care discussions do not destroy hope, but can reveal unrealistic expectations for surgery and outcomes. [Table: see text]
Advanced cancer patients' priorities regarding wishes at the end of life: A randomized controlled study.
Authors: Delgado-Guay Marvin Omar , Rodriguez-Nunez Alfredo , De la Cruz Vera J , Frisbee-Hume Susan , Williams Janet L. , Wu Jimin , Liu Diane D , Fisch Michael , Bruera Eduardo
Published: February 2017

44

Background: Conversations about wishes around the end-of-life(EOL) are challenging for clinicians. There is limited literature about the type and stability of patient’s reported EOL planning priorities. We compared a set of 36 cards (“Go-wish-Game”: GWG) v. a paper list of statements (LOS) to assist patients in establishing priorities. Methods: Randomized controlled study. Pts. were randomized to the GWG or to 36 LOS and were asked to categorize them as very, somewhat, or not important; Group A received LOS followed by LOS 4-24 hours later; group B: GWG-GWG; group C: GWG-LOS, and group D: LOS-GWG. The State-Trait Anxiety inventory for Adults(STAI) was done after the first set of questionnaires. Results: 100 pts. Median age (IQR): 56 (27-83) years. 60% female. 68% White, 17% Hispanic, and 9% African-American. 62% married. Age, marital status, religion, education and cancer diagnosis were not significant different among groups. All pts. were able to complete the GWG. 43/50 (88%) agreed that instructions of GWG were clear. 45/50 (92%) agreed that GWG was easy to understand. 31/50 (64%) patients exposed to both tools, preferred GWG. 39/50 (79%) expressed that GWG did not increased their anxiety. 31/50 (63%) expressed that having conversations about priorities near EOL is beneficial to them (p=NS). STAI median (IQR) score after GWG was 48 (39-59) v. 47 (27-63) for LOS, p=0.2952. The 10 most common “Very important” wishes expressed by pts. the first and second time they received the test (%; Spearman, p-value) were: to be at peace with God(74% v. 71%; r=0.73, p<0.0001), to pray(62% v. 61%, r=0.53, p<0.0001), to have my family with me(57% v. 61%; r=0.23, p=0.02), to be free from pain(54% v. 60%, r=0.31, p=0.001), not being a burden to my family(48% v. 49%, r=0.23, p=0.02), to trust my doctor(44% v. 45%; r=0.49, p<0.0001), to keep my sense of humor(41% v. 45%; r=0.53, p<0.0001), to say goodbye to important people in my life(41% v. 37%; r=0.46, p<0.0001); to have my family prepared for my death(40% v. 49%; r=0.48, p<0.0001). Conclusions: EOL wishes were similar and persistent using both GWG and LOS. Completing both GWG and LOS did not increase anxiety. All patients were able to complete and most preferred GWG.
Associations between hospice use and end-of-life (EOL) care outcomes in patients with advanced cancer.
Authors: Kumar Pallavi , Hatfield Laura , Wright Alexi A. , Temel Jennifer S. , Keating Nancy Lynn
Published: February 2017

53

Background: There are few data examining the association between hospice care (HC) and the quality of advanced cancer patients’ EOL care. We explored associations between HC and family-reported relief of patients’ symptoms, quality of EOL care, and concordance with patients’ previously expressed wishes for EOL care and place of death. Methods: We surveyed 2,307 family members of deceased patients with advanced lung cancer (LC) or colorectal cancer (CRC) who were enrolled in the Cancer Care Outcomes Research and Surveillance (CanCORS) study (a national prospective, observational cohort study). We used propensity score matching to compare family-reported outcomes for patients who did or did not receive HC, including prevalence and relief of common symptoms (pain, dyspnea, depression or anxiety), quality of EOL care, and concordance with wishes for EOL care and place of death. Results: In 985 matched pairs, patients with LC or CRC who received HC had higher pain, distress from pain, and depression and/or anxiety, but more appropriate relief of pain and dyspnea (Table). HC was associated with a higher family-reported quality of EOL care, greater concordance with patients’ EOL care wishes, and higher likelihood of death in a preferred place. Conclusions: Patients receiving HC had greater symptoms compared to non-hospice enrollees, but had more appropriate symptom relief. HC for patients with LC or CRC is also associated with higher quality of EOL care, and concordance with wishes for EOL care and place of death as reported by bereaved family members. These data demonstrate the need to improve hospice utilization for advanced cancer patients. [Table: see text]
Predictors of trust in the medical profession among cancer patients receiving palliative care: A preliminary study.
Authors: Tanco Kimberson , Rhondali Wadih , Park Minjeong , Liu Diane D , Bruera Eduardo
Published: February 2017

60

Background: Trust influences health care through the willingness to seek and continue care, disclose sensitive information, adhere to treatment, and satisfaction with care. In a recent prospective study of patient perception of physician compassion, the degree of trust in the medical profession was found to be significantly associated with higher perception of compassion. In this secondary analysis, we explored the association between trust and other demographic and psychosocial factors. We also explored the performance of the single item Degree of Trust scale compared to the validated 5-item Trust in Medical Profession scale. Methods: A secondary analysis of prospectively collected data was performed. Trust scores completed by 100 patients were correlated with age, gender, ethnicity, educational level, anxiety, depression, hopefulness, and a 0 (best) – 10 (worst) Degree of Trust question. Results: Scores were 13, 11-14 [median, IQR; inversely scored] for Trust in Medical Profession and 2, 1-4 [median, IQR] for Degree of Trust with moderate correlation [r = 0.587, p < 0.001]. On evaluating performance of Degree of Trust scale to the validated Trust in Medical Profession scale, a moderately high performance was found [Youden’s J = 0.73; Topleft = 0.21]. Older age [57, 49-65 (median, IQR), p = 0.02] lower depression scores [6,3-9 (median, IQR), p < 0.01] and more hopefulness [22,20-25 (median, IQR), p = 0.01] were associated with higher levels of trust. Conclusions: Trust was associated with older age, less depressed and more hopeful patients. A single 0-10 item trust scale was found to perform adequately compared to a multiple item questionnaire.
Cancer symptom scale preference: One size to fit all?
Authors: O'Connor Brenda , Jeter Kirby , Blackwell Siobhan , Burke Lucy , Conway Emma Victoria , Moran Catherine , Cremen Iseult , Ui Dhuibhir Pauline , Joyce David , Walsh Declan
Published: February 2017

69

Background: Systematic assessment in cancer is conducted by a variety of instruments. Such assessment is important as comprehensive instruments detect more symptoms than casual clinical evaluation. In choosing assessment scales for polysymptomatic cancer patients one must consider the burden of assessment to ensure satisfactory completion rates. This study investigated patient preference and clinical utility of symptom assessment scales. Methods: A prospective survey was conducted in an Irish palliative medicine inpatient unit.Consecutive cancer admissions were recruited within 7 days. Patients’ preferences were elicited with regards to 3 symptom assessment scales; categorical response (CRS), numerical rating (NRS), and visual analogue (VAS), across 3 common symptoms; appetite loss, pain, and tiredness. Participants selected their preferred scale per symptom. We determined the clinical utility of each scale, defined by ease of completion as judged by an observer. Results: 100 participants wererecruited,aged 38-93 years (x̅ = 71 years; SD=11.6). Median European Cooperative Oncology Group (ECOG) score was 2 (range 0-4). Participants preferred CRS for appetite loss (48%) and tiredness (40%), and NRS for pain (44%). VAS was consistently the least preferred measure. Scale preference was fully consistent across symptoms for 52% of patients, with just 4% choosing a different scale per symptom. There was moderate agreement between participant scale preference and ease of completion as determined by observer (Pain: K=0.486; Fatigue: K=0.452; Appetite loss K=0.364). Conclusions: (1) Most participants had a specific scale preference which was consistent across symptoms, (2) CRS was preferred overall, (3) Participants did not need to experience a symptom to have a preference, (4) VAS should be used with caution in hospice clinical care or research, (4) Symptom assessment scales should be carefully selected for clinical and research purposes.
Patterns of failure and morbidity associated with palliative intervention in patients with malignant biliary obstruction.
Authors: McFarlane Matthew Ryan , Pillai Anil , Porembka Matthew , Meyer Jeffrey John , Kubiliun Nisa , Folkert Michael Ryan
Published: February 2017

71

Background: Outcome for patients with malignant biliary obstruction is poor. While endoscopic or percutaneous procedures provide palliative benefit, stents often occlude or migrate, and drains frequently fail requiring repeat procedures in medically fragile patients. As part of a multidisciplinary effort to improve outcomes in this population, we undertook an investigation to determine rates of stent and drain failure and morbidity to identify areas of potential improvement. Methods: After Institutional Review Board approval, retrospective review of all cancer registry patients undergoing percutaneous or endoscopic intervention for biliary obstruction from 1/2004-10/2014 and billing reports from 11/2012-10/2014 identified 230 patients. Cases of biliary obstruction due to malignancy requiring intervention were selected, resulting in 94 evaluable patients. Charts were reviewed to determine dates and cause for stent and/or drain replacement and morbidity. Results: Of 94 analyzable patients, median age was 60 years and 49 were male (52%). Malignant cause of obstruction was gastric/colorectal in 16 (17%), biliary in 37 (39%), hepatocellular in 7 (7%), and pancreatic in 34 (36%). Stenting was part of the initial procedure in 47 (50%), and drain placement in 49 (52%). Ultimately 60 (64%) patients underwent stent procedures and 82 (87%) patients required drains. Of the stented patients, 27 (45%) required repeat stenting, and 13 (22%) required > 1 stent replacement. Of the patients who underwent drainage procedures, 68 (83%) required repeat drainage, and 52 (63%) required > 1 repeat drainage procedure. Cholangitis was observed following stent in 5 (5%) of patients, 60% in patients undergoing > 1 stent procedures. Median survival after initial procedure was 12 months; for patients requiring repeat procedures, median survival was 4.5 months. Conclusions: Malignant biliary obstruction is a morbid disease with high rates of reocclusion requiring repeat procedures, which may negatively impact outcome and increase healthcare cost. Efforts to reduce the rates of repeat procedures are critical to address this clinical need.
Outpatient palliative care needs of metastatic cancer patients treated with radiation therapy.
Authors: Rich Shayna Eliana , Castagno Jacqueline , Beaulieu Rebecca , Yeung Anamaria R
Published: February 2017

73

Background: It is unclear how frequently patients with metastatic cancer treated with radiation therapy have unmet physical, psychological, spiritual, and practical needs of patients. This study aims to determine the level of support needed to meet this burden. Methods: We performed a telephone survey to evaluate the unmet needs of living patients with stage IV metastatic cancer treated with radiation therapy at a single institution in the priot six months. Data were collected using the Palliative care Outcome Scale, a validated 12-question survey about unmet patient needs, and its associated symptom scale. We examined patient treatment history by reviewing medical records. Among 87 eligible patients treated, 45 had died, 19 could not be reached, and two declined participation. Thus, 21 patients were included in the analysis. Results: Most frequent diagnoses were lung (24%; 5/21) or colorectal cancer (19%; 4/21). Most patients’ recent radiation course had palliative intent (62%; 13/21), but eight had received ablative radiation. No patients were undergoing radiation treatment when the survey was administered, and 57% (12/21) were receiving chemotherapy. Despite most patients seeing a physician within 2 weeks of the survey (median 1.7 weeks; range 0-11.4 weeks), most patients reported pain (67%) and anxiety (57%), and about 50% reported these issues as moderate or worse. At least one-third of patients reported having each need unmet. Patients complained of a median of five symptoms, with 57% of patients reporting any symptom severe. Patients on chemotherapy (n = 12) reported more symptoms and increased symptom severity, but 44% of patients reported moderate pain even among those not undergoing any therapy. Conclusions: Patients with metastatic cancer recently treated with radiation therapy continue to have substantial needs that are often not being met by standard oncologic care, despite recent visits with physicians. Although many of these patients are receiving chemotherapy and may be identified for palliative care programs through the medical oncology service, radiation oncology clinics should also routinely integrate quality palliative care for patients with metastatic cancer.
Symptom burden and palliative care for patients with multiple myeloma: Cancer Experience Registry findings.
Authors: Buzaglo Joanne S. , Miller Melissa F , Karten Clare , Longacre Margaret , LeBlanc Thomas William
Published: February 2017

81

Background: Multiple myeloma (MM) patients are living longer with treatment advances yet remain challenged by complications and adverse treatment effects. Concurrent oncology/palliative care can improve symptom burden and quality of life for cancer patients, but the benefits of concurrent care for the MM symptom burden is not well described. Methods: From July 2013-2014, the Cancer Support Community (CSC) registered 495 MM patients to the Cancer Experience Registry: MM, an online initiative to study and raise awareness about MM’s psychosocial impact. Registrants were recruited through an outreach program including the CSC and The Leukemia & Lymphoma Society networks of communities and resources. 331 US-based registrants completed surveys about their MM history, treatment, and symptoms. Results: Median respondent age was 64 years; 54% were female, 87% Caucasian. Median time since diagnosis was 4.5 years, and 40% reported experiencing a relapse. Several symptoms interfered (quite a bit or very much) with respondents’ daily life: fatigue (40%), bone pain (22%), peripheral neuropathy (22%) sleep disturbance (21%), GI toxicity (16%), and mood swings (10%). The daily effects of fatigue, pain, sleep disturbance and mood swings were associated (p < 0.05) with distress. 36% did not report all symptoms and side effects (SEs) to their health care team (HCT). The most common reason was “I don’t think anything can be done about these problems.” More than half (58%) reported sleep disturbances related to steroids, and 46% experienced weight gain, 41% mood swings, and 39% edema. One-third (34%) reported their HCT never told them steroids could cause this. 85% felt their HCT prepared them (somewhat, quite a bit, or very much) to manage SEs of MM treatment, yet half (50%) felt little or no control over the physical SEs of MM and its treatment. Conclusions: Patients with MM experience significant symptom burden that interferes with daily living but underreport symptoms to the HCT. Many symptoms are amenable to interventions by palliative care specialists, which may improve MM patients’ quality of life. These findings suggest the need for more integration of palliative care services with oncology and other care for MM patients.
A web-based program to engage informal caregivers to support patients through chemotherapy.
Authors: Silveira Maria , Given CW , Sikorskii Alla , Given Barbara Ann , Cease Kemp Bailey , Piette John D
Published: February 2017

90

Background: Most interventions to improve cancer symptoms rely on patient self-management, which can be challenging for some. "Cancer CarePartners" is a system designed to engage informal caregivers to support patients' quality of life as they receive chemotherapy. The system provides weekly, automated telephonic symptom assessment to patients, and symptom alerts plus tailored advice to their caregivers. We conducted a randomized control trial to test the efficacy of this program in controlling symptoms and improving adherence to chemotherapy. Methods: Consenting patients with solid tumors undergoing chemotherapy that reported any symptom at ³3 (out of 10) and had a consenting caregiver were randomly assigned to 10 w of either Cancer CarePartners or an attention control. Arms were balanced for lung cancer and caregiver type. Subjects were surveyed at 0, 10, and 14 weeks; charts were reviewed at 14 weeks. We tracked patient and caregiver use of the system. Results: 834 patients were referred to the study and 371 (45%) met eligibility criteria. Among the 151 (41%) patients who consented, 91% entered the study and 82% completed the trial. Patients completed assessments for most weeks on study (mean 7.7 intervention vs. 8.3 control). Intervention caregivers logged into the Website an average of 4.1 times over 10 weeks (range 0-10). At 10 weeks, intervention patients experienced lower summed symptom severity than controls (mean 19.5 vs. 23.2), but this was not statistically significant after adjusting for baseline symptoms (P = 0.107). They also experienced fewer inpatient stays (mean 0.19 vs. 0.34, P = 0.1814) and phone calls with providers (mean 0.46 vs. 0.62, P = 0.3019) than controls did. They received more chemotherapy (# agents per cycle 3.6 vs. 3.1 P = 0.0395; # agents per infusion 2.2 vs. 2.0 P = 0.0054). Intervention caregivers reported less depression (CESD Coef -1.08, P = 0.094, 95% CI -2.35 to 0.19), and similar burden as controls. Conclusions: Cancer CarePartners enhances caregiver support for patients and improves their symptom management and adherence with chemotherapy as a result, while adding little burden to the caregiver. One limitation of the study is that recruitment was less than expected. Clinical trial information: IIR 08-309.
Understanding causes of distress in women with gynecologic cancer.
Authors: Bevis Kerri S. , Kvale Elizabeth Ann , Rocque Gabrielle , Cantuaria Guilherme Henrique , Scalici Jennifer , Rocconi Rodney Paul , Finan Michael , Acemgil Aras , Li Yufeng , Taylor Richard A. , Demark-Wahnefried Wendy , Kenzik Kelly , Meneses Karen , Martin Michelle , Fouad Mona N. , Partridge Edward E. , Pisu Maria
Published: February 2017

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Background: Lay patient navigators can screen patients using a distress tool (DT) to identify and address multiple patient concerns. Patient-reported distress can be used to characterize the needs of patients with ovarian, endometrial, and cervical cancer through all phases of care from initial diagnosis through active treatment and into survivorship. Methods: The Patient Care Connect Program (PCCP) includes 12 cancer centers throughout Alabama, Mississippi, Georgia, Florida, and Tennessee and navigates Medicare beneficiaries with cancer. Within the PCCP, navigators documented distress levels, causes of distress, and requests for intervention. Distress screening results were used to describe needs of patients with gynecologic malignancies and to assess effective resolution of distress. Results: Initial DT results were collected on 360 patients with gynecologic cancers: 206 (57%) ovarian, 111 (31%) endometrial, and 43 (12%) cervical cancers. Fifty-six (16%) were African American. Twenty-four percent of patients reported a distress score ≥ 4 and 4% reported scores ≥8. Physical symptoms most frequently caused distress (44%) particularly fatigue, pain, and neuropathy. Practical problems (11%), informational needs (16%) and emotional issues (19%) were also common. Patients were most likely to request assistance with transportation (63%), financial/insurance issues (77%), and nutritional concerns (75%). Lay navigators were able to address these concerns in 92% of patients. Conclusions: Gynecologic cancer patients report diverse sources of distress extending beyond symptom management. By administering DTs, patient navigators may effectively facilitate resolution of patient identified distress. The project described was supported by Grant Number 1C1CMS331023 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this abstract are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
Pruritus as an unmet palliative care need in cancer patients: A retrospective cohort study of a Duke patient-reported outcomes database.
Authors: Hudson Kathryn Elizabeth , Wolf Steven Paul , Pupa Mary Ruth , King Danielle Grace , Locke Susan C. , Abernethy Amy P , LeBlanc Thomas William
Published: February 2017

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Background: For cancer patients, the impact of pruritus is not well known, and may be increasing in incidence and severity for those receiving targeted agents. We aimed to describe pruritus in patients with solid tumors, assessing the incidence, pattern, treatments, and associations with cancer types and therapies. Methods: From 2009-2011, patients seen in the Duke Cancer Institute solid tumor clinics directly reported their symptoms on electronic tablets as part of routine care, using Patient Care Monitor 2.0. Of the resulting 17,338 encounters, >1,000 patients reported moderate-severe itching (score of >3 out of 10). The analysis cohort included 215 patients who reported severe itching (>6 out of 10) on at least one visit (total visits = 536). We reviewed charts to abstract demographics, diagnosis, stage, cancer therapy, comorbidities, anti-pruritus therapy, and provider response, and applied descriptive statistics and chi-square analyses. Results: Most patients had advanced disease (56% stage IV), and had breast (36%), lung (23%), kidney (8%), colorectal (6%), or prostate cancer (5%). Thirty percent were not on active therapy, 27% were receiving a targeted therapy, 29% were receiving cytotoxic chemotherapy, and 14% were receiving both. Pruritus persisted in 56% of patients, and resolved but recurred in 10%. Patients receiving chemotherapy were more likely to have severe rather than moderate pruritus (p 0.01), while those receiving targeted drugs were more likely to have persistent pruritus (p 0.03). Potentially high-risk targeted therapies including EGFR inhibitors, multi-kinase inhibitors, and mTOR inhibitors were not associated with severity or persistence of pruritus. Only 20% of patients were receiving an anti-pruritus treatment. Clinicians documented discussing pruritus in just 28% of cases, and addressed it directly only 10% of the time. Only 5% of patients were started on a new anti-pruritus treatment. Conclusions: Pruritus is common among patients with advanced cancer, and occurs across a range of cancer types and treatments. Pruritus is frequently not recognized or addressed by clinicians, and appears to be an unmet palliative care need in oncology.
Evaluation of α-1-acid glycoprotein as a prognostic factor of survival in patients with stage II-III esophageal carcinoma treated with neoadjuvant docetaxel, cisplatin, and fluorouracil chemotherapy followed by surgery.
Authors: Sasaki Yusuke , Kato Ken , Furuta Koh , Takahashi Naoki , Shoji Hirokazu , Honma Yoshitaka , Iwasa Satoru , Okita Natsuko T. , Takashima Atsuo , Hamaguchi Tetsuya , Yamada Yasuhide , Boku Narikazu
Published: February 2017

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Background: Serum α-1-acid glycoprotein (AAG) level was an independent predictor of response and a prognostic factor of survival in patients with non-small cell lung cancer treated with docetaxel chemotherapy. However, it has not been determined whether AAG is associated with the outcomes of esophageal cancer patients who have been treated with a combination of docetaxel, cisplatin and 5-fluorouracil (DCF) as neoadjuvant therapy. Methods: This retrospective study included a cohort of 39 patients with clinical stage II/III esophageal cancer, based on the International Union Against Cancer TNM classification system 7th edition, who were treated with neoadjuvant DCF followed by surgery. DCF consisted of docetaxel (70mg/m2) and cisplatin (70mg/m2) on day 1, and continuous infusion of 5-fluorouracil (750mg/m2/day) on days 1-5, with this regimen repeated every 3 weeks up to three cycles. Patients were divided into groups by median value of baseline AAG levels. Patient characteristics, preoperative clinical stage, chemotherapy effect, and survival were compared between the high and low AAG groups. Results: The clinical stage IIA, IIB, IIIA, IIIB and IIIC were 4, 4, 14, 17 and 0, respectively. The completion rate of three cycles of chemotherapy was 76.9% (30/39). All patients underwent surgery and the R0 resection rate was 97.4% (38/39). The best overall response rate of DCF was 48.7% with a pathological complete response of 5.1%. The 2-year progression-free survival and overall survival (OS) rates were 60.5% and 76.9%, respectively. The median serum AAG was 95 g/L, ranging from 57 to 228 g/L. A trend of lower response rate (35.0% vs. 57.9%; P = 0.20) and shorter OS (median not reached; hazard ratio [HR] 2.08; P = 0.24) was observed in patients with a high AAG level (AAG > 95 g/L) compared with a low AAG level (AAG ≦ 95 g/L). Multivariate analysis showed an AAG level hazard ratio of 1.60 (P = 0.59) for OS. Conclusions: There was a trend toward improved response and survival with low serum AAG level, for patients with esophageal cancer who received neoadjuvant DCF chemotherapy.