bluuebunny/crossref_metadata_2025 huggingface dataset:
Intended and unintended consequences: Ethics, communication, and prognostic disclosure in pediatric oncology.
Authors: Marron Jonathan Michael , Kang Tammy I , Cronin Angel , Mack Jennifer W.
Published: February 2017

10

Background: Most patients wish for all available information about their prognosis, but physicians can be hesitant to discuss prognostic information with patients, particularly those with poor prognoses. For some, concerns that this will cause anxiety, depression, or decreased hope outweigh the ethical obligation to provide such information. Methods: We surveyed 353 parents of children with newly diagnosed cancer at the Dana-Farber/Boston Children’s Cancer and Blood Disorders Center and the Children’s Hospital of Philadelphia. We used multivariable logistic regression to assess associations between parental report of elements of discussions of prognosis with the child’s oncologist (quality of information, quality of communication, prognostic disclosure) and the intended/unintended outcomes of these discussions (trust, hope, peace of mind, depression, anxiety). Analyses were stratified by the child’s prognosis: favorable ( ≥ 75% likelihood of cure) or less favorable ( < 75% likelihood) as reported by the oncologist. Results: Among parents of children with less favorable prognoses (n = 140), those who reported receiving high quality information from the oncologist expressed greater peace of mind (odds ratio [OR] 4.44, 95% confidence interval [1.53, 12.90], p < 0.01), and those who reported their oncologist to have provided high quality communication endorsed greater trust in the oncologist (OR 3.25 [1.22, 8.70], p = 0.02) and feelings of hope (OR 2.96 [1.24, 7.03], p = 0.01). Parents who received more information about prognosis were not significantly more anxious (p = 0.82), depressed (p = 0.55) or less hopeful (p = 0.86) than those who received less prognostic information. Similar findings were seen in the more favorable prognosis subset and the overall cohort. Conclusions: We find no evidence that greater prognostic disclosure leads to the unintended consequences of increased anxiety, depression, or decreased hope, even in parents of children with less favorable prognoses. Rather, communication processes may increase the intended consequences of peace of mind, trust, and hope, supporting the discussion of prognosis with all parents, even those of children with a lower likelihood of cure.
Comparison of older adult symptom occurrence rates in a geriatric-oncology clinic with meta-analysis for adults receiving chemotherapy.
Authors: Flannery Marie Anne , Magnuson Allison , Guido Joseph John , Peppone Luke Joseph , Dale William , Mohile Supriya Gupta
Published: February 2017

102

Background: The majority of cancers occur in older adults, yet there is limited information on their symptom experience because they are under-represented in studies. To address this gap we examined registry data from two partnered geriatric oncology clinics, our aims are to: 1) identify older patients’ symptom occurrence rates and 2) compare symptom occurrence rates to published norms for adults with cancer. Methods: At presentation, patients completed the MD Anderson Symptom Inventory with symptoms coded as present or absent. Prevalence rates were compared to rates from a meta-analysis (Reilly et al., 2013) of adult cancer patients receiving chemotherapy which included pooled data from 21 studies (age M = 58 years, Range 118 = 97 years.) Differences were tested with Chi-Square. Results: As compared to published data, older patients (N = 291, M = 80.6 years, SD = 6.47, 52% > 80 yrs.) reported higher rates for the following symptoms: drowsiness (65% vs. 43%), trouble remembering (60% vs. 44%), distress (50% vs. 41%), sadness (49% vs.34%) (p’s < .01), and dry mouth (55% vs. 48%, p = .03). Lower rates were reported for nausea/vomiting (23% vs 40%/ 13 vs 27%, p’s < .001). There was no significant difference for the rates of fatigue (60%), difficulty sleeping (52%), pain (50%), decreased appetite (49%), dyspnea (48%), and numbness/tingling (38%). Conclusions: Older adults referred to specialized geriatric oncology clinic present with multiple symptoms. These patients had a mean age of eighty, may reflect the frail and vulnerable and were not often receiving active treatment. Results reinforce that it is especially important to assess and intervene on cognitive and psychological status in older patients. Nausea/Vomiting were less common in older adults perhaps due to lower chemotherapy rates. Limitations exist as we were not able to control for other factors affecting symptoms in the analysis. Nonetheless, results are consistent with older adults reporting many symptoms at a similar or higher rate than prior studies including all adults receiving chemotherapy. Increased study of the symptom experience in older oncology patients is critical to advance palliative care and symptom science.
Predictors and prognostic importance of weight change in adult solid tumors.
Authors: Shrotriya Shiva , Walsh Declan , Aktas Aynur , Estfan Bassam N.
Published: February 2017

103

Background: Body weight change in adults with solid tumors was examined in outpatients. Objective was to determine if demographics, clinical and biochemical characteristics were associated with change in weight between visit 1 and visit 2. Examine if weight change and related parameters were associated with survival. Methods: Electronic medical records (EMR) from a tertiary cancer center retrospectively reviewed from 2009-2011. Body weight and other clinical parameters on visit 1 - within a year post diagnosis; visit 2 ≥3 weeks after visit 1. Weight change categorized as: weight gain, 0-5%, 5.01-10%, >10%. Ordinal logistic regression and Cox proportional hazards utilized for WL predictors and prognostic factors respectively. Results: N = 5,901; Mean age (±SD): 61 ± 12 years; 82% were Caucasians; 16% African Americans. Common cancers were prostate 19%; breast 15%; lung 15%; head and neck 6%; colorectal 6%; others 12%. Metastatic disease was present in 18%. Bone, brain, lymph nodes – were common metastatic sites. 45% had radiotherapy; 41% chemotherapy. Median weight change from visit 1 to visit 2 = -1 (-48, 66) kgs. Weight loss (WL) in 57% (≤5%: 30%, 5.01-10%: 13%, >10%: 14%). Different primary cancer sites, number of metastatic sites, radiotherapy/chemotherapy/hormonal therapies, older age, body mass index (BMI), and albumin predicted weight change. Median survival in 5.01-10.0% WL= 9.4 months, >10.0% = 5.3 months, and not observed ≤ 5%. Conclusions: 1. Majority lost ≤5% of body weight by visit 2. 2. Esophagus, head and neck, and pancreas (primary) - the greatest risk of WL; prostate – lowest. 3. High BMI predicted greater WL compared to normal or underweight. 4. ≤5% WL had a survival advantage compared to 5.01-10% and >10%. 5. WL remained prognostic for survival after adjusting for other prognostic factors.
Defining high-quality palliative care in oncology practice: An ASCO/AAHPM Guidance Statement.
Authors: Bickel Kathleen Elizabeth , McNiff Kristen K. , Buss Mary K. , Kamal Arif , Lupu Dale , Abernethy Amy Pickar , Broder Michael S. , Shapiro Charles L. , Acheson Anupama Kurup , Malin Jennifer , Evans Tracey L. , Krzyzanowska Monika K.
Published: February 2017

108

Background: When integrated into routine oncology care, palliative care can improve symptom burden, quality of life, and patient and caregiver satisfaction. However, not all oncology practices have access to subspecialty palliative medicine for referral. This project endeavored to define what constitutes high-quality primary palliative care as delivered by medical oncology practices. Methods: An expert steering committee developed a list of 966 palliative care service items, divided into nine domains, each describing an aspect of palliative care delivery for patients with advanced cancer. Using a modified Delphi methodology, 31 multi-disciplinary panelists ranked each service item according to importance, feasibility and scope. Results: Panelists endorsed the highest proportion of palliative care service items in the domains of End-of-Life Care (81%); Communication and Shared Decision-Making (79%); and Care Planning (78%). Lowest proportions were in: Spiritual and Cultural Assessment and Management (35%) and Psychosocial Assessment and Management (39%). In the largest domain, Symptom Assessment and Management, there was consensus that all symptoms should be assessed and managed at a basic level with more comprehensive management for common symptoms such as nausea, vomiting, diarrhea, dyspnea and pain. Under the domain of Appropriate Palliative Care and Hospice Referral, there was consensus that oncology practices should be able to describe the difference between palliative care and hospice to patients and refer patients with an expected survival of under 3 months or poor performance status (Zubrod 3-4) to hospice. Conclusions: This statement describes high-quality palliative care for patients with advanced cancer or high symptom burden, as delivered by oncology practices. Oncology providers wishing to enhance palliative care delivery may find the guidance useful to inform operational changes and quality improvement efforts.
Pathways, partners and payers: The trifecta of palliative care integration.
Authors: Portman Diane G. , Thirlwell Sarah
Published: February 2017

129

Background: Moffitt Cancer Center has developed proprietary oncology clinical pathways. Multiple external partnership agreements which require adoption of these pathways have been completed. Our Center has enacted new cancer care delivery and payment arrangements with payers to foster cost and quality balance via use of the pathways and earlier involvement of palliative care (PC). Methods: Executive and PC leadership collaborated with the clinical pathways and strategic alliance teams to identify high priority disease states for integration of PC. Working with oncologist pathway developers, critical junctures in the pathways for inclusion of PC consultation were proposed and refined. EHR mechanisms to promote pathway adherence by clinicians were initiated. The value of pathway utilization and care coordination to involve PC was promoted to prospective oncology partners and payers. Results: PC has been mandated in oncology clinical care pathways, with a focus on thoracic, breast, gastrointestinal, prostate, gynecologic and hematologic malignancies, as directed by specific payer arrangements. Partnerships have expanded, resulting in greater utilization of PC by other centers as well. Increased referral volumes to PC, broader symptom control, and enhanced advance care planning have resulted. Conclusions: Incorporation of PC in oncologic clinical care pathways, with dissemination to internal providers, external partners and as part of novel payment models, optimizes PC integration. [Table: see text]
Interdisciplinary palliative care for patients with lung cancer.
Authors: Ferrell Betty R. , Sun Virginia , Hurria Arti , Cristea Mihaela C. , Raz Dan , Kim Jae , Reckamp Karen L. , Williams Anna Cathy , Borneman Tami R. , Uman Gwen , Koczywas Marianna
Published: February 2017

130

Background: Palliative care, including symptom management and attention to quality of life (QOL) concerns, should be addressed throughout the trajectory of a serious illness such as lung cancer. This study tested the effectiveness on an interdisciplinary palliative care intervention for patients with stage I-IV non-small cell lung cancer (NSCLC). Methods: Patients undergoing treatments for NSCLC were enrolled in a prospective, quasi-experimental study whereby the usual care group was accrued first followed by the intervention group. Patients in the intervention group were presented at interdisciplinary care meetings and appropriate supportive care referrals were made. They also received four educational sessions. In both groups, QOL, symptoms, and psychological distress were assessed at baseline and 12 weeks using surveys which included the FACT-L, FACIT-Sp-12, LCS, and the Distress Thermometer. Results: A total of 491 patients were included in the primary analysis. Patients who received the intervention had significantly better scores for QOL (109.1 vs. 101.4; p < .001), symptoms (25.8 vs. 23.9; p < .001), spiritual well-being (38.1 vs. 36.2; p < .001), and lower psychological distress (2.2 vs. 3.3; p < .001) at 12 weeks, after controlling for baseline scores, compared to patients in the usual care group. Patients in the intervention group also had significantly higher numbers of completed advance care directives (44% vs. 9%; p < .001), and overall supportive care referrals (61% vs. 28%; p < .001). Conclusions: Interdisciplinary palliative care in the ambulatory care setting resulted in significant improvements in QOL, symptoms, and distress for NSCLC patients.
Palliative care consultation for patients enrolled in cancer clinical trials.
Authors: Nipp Ryan David , Powell Elizabeth , Moy Beverly
Published: February 2017

139

Background: Cancer clinical trials often enroll patients with advanced cancer, yet trial participation should not preclude the appropriate use of palliative care (PC) services for these patients. We sought to describe rates and correlates of PC consultation in clinical trial patients and identify factors associated with use of PC. Methods: We prospectively collected data on patient characteristics and rates of PC consultation among all patients enrolled in cancer clinical trials at Massachusetts General Hospital in 2014. We used multiple logistic regression with purposeful selection of covariates to identify factors associated with PC consultation. Results: Of 1,218 clinical trial patients (mean age = 58 years; 643 (53%) female), 781 (64%) were married and 851 (70%) had metastatic disease. All cancer types were represented, but hematologic cancers (21%) were most common. Of those who had tumor genotype testing, 340 (62%) had a somatic mutation. Overall, 177 (15%) received PC consultation. Of those with metastatic disease, 149 (18%) received a PC consult. Metastatic disease, being unmarried, and absence of a somatic tumor mutation correlated with receipt of a PC consult. Conclusions: We found that a minority of cancer clinical trial patients receive PC consultation. Having metastatic disease and being unmarried correlated with receipt of PC consultation, thus highlighting a population likely needing additional supportive care. Presence of a somatic mutation was inversely associated with receiving PC consultation, suggesting that disease biology may impact patients’ supportive care needs or presence of these mutations influences clinician decisions about the need for PC services. These data help identify the factors associated with appropriate use of PC, and add to our understanding about the use of these services in cancer clinical trial patients. [Table: see text]
Evaluation of the efficiency of an embedded palliative nurse practitioner in an oncology clinic.
Authors: Walling Anne M. , D'Ambruoso Sarah , Pietras Christopher , Malin Jennifer , Hurvitz Sara A. , Watts Frances , Ferrell Bruce , Zisser Ann , Wenger Neil
Published: February 2017

146

Background: We embedded a palliative nurse practitioner in 2 oncologists’ clinics in March 2014 using a reproducible training program. After one year, patients with advanced cancer receiving care in the embedded model clinics, compared to other oncologists’ clinics, were more likely to have advance care planning performed and to die receiving hospice. In order to expand the intervention to other oncologists, we evaluated the efficiency in our model of care delivery. Methods: We reviewed overall caseload and a subset of patient encounters in depth to understand how much of the NP's practice could be conducted by other staff to inform alternate clinical models of palliative care delivery in an oncology clinic. Overall time spent and time spent per task (Symptom Assessment Basic (SAB), Symptom Assessment Medical (SAM), Symptom Assessment Psychosocial (SAP), Communication Basic (CB), Communication Complex (CC)) was recorded for 16 patient encounters. We also completed 3 days of time motion study in which a trained observer tracked the NP's daily activities from minute to minute. Results: After part-time clinical participation over the first year of the program, the NP had seen 68 initial consults and 141 follow-up consults, which were potentially billable. She also had 120 encounters where she met a patient with an oncologist and 158 email or phone encounters that were not billable. Mean duration of a visit was 56 minutes (range 40-70 minutes) and about half of this time was spent on symptom assessment and communication topics requiring an MD or NP (SAM and CC), whereas half of the time was spent on topics that potentially could be covered by an RN (SAB or CB) or an MSW (SAB, SAP, CB). Time motion study revealed that a significant amount of time was spent with email correspondence and talking with other providers for care coordination. Conclusions: Palliative care is time consuming and much of the work is not reimbursed by a traditional fee for service model. Approximately half of the time spent by the NP in our embedded program potentially could have been completed by an RN or other interdisciplinary staff with training in palliative care under supervision of a physician. We plan to add an RN case management component to our model of care delivery.
Evaluation of spiritual needs assessments in oncology palliative care: Results of an improvement project.
Authors: Thirlwell Sarah , Storms Valerie , Kennedy Mareda , Portman Diane G.
Published: February 2017

161

Background: Addressing all facets of serious illness requires attention to patients’ spiritual concerns. At our Cancer Center, we sought to ensure that palliative care (PC) inpatients received evidence-based spiritual care. Methods: Chaplaincy Care, Supportive Care Medicine, and Quality and Safety Departments partnered to improve spiritual care using an iterative Plan-Do-Check-Act Cycle approach. Evidence-based spiritual practices were defined in accordance with the Association of Professional Chaplains and Clinical Practice Guidelines for Quality PC of the National Consensus Project. As a member of the Global Palliative Care Quality Alliance, we also used the web-based Quality Data Collection Tool (QDACT) to guide spiritual assessment. Electronic health record templates were revised to support complete and timely documentation. We monitored performance based on National Quality Forum Measure #1647 for discussion of spiritual/religious concerns. Performance was reviewed monthly by Leadership and with the Chaplaincy Staff. Opportunities to improve performance were discussed and adjustments in practice were made. Results: A total of 1609 oncology patients (average of 89/month) were seen by the inpatient PC team from November 2013–April 2015. With transparent performance reporting and resolution of barriers to spiritual assessment, an increase from 36 to 96% was noted for the percentage of patients with documented spiritual or religious concerns. Spiritual assessment using QDACT indicated that most patients report high spiritual well-being, spiritual peace, and a religious affiliation. Conclusions: As the result of our efforts, the majority of PC oncology patients at our center now have assessment and documentation of spiritual and religious concerns. A team-based approach to quality improvement successfully fostered the integration of spiritual care into oncology palliative care. [Table: see text]
Yoga in a palliative care suite: Promoting self-care amongst nurses and practitioners.
Authors: Gancio Cheryl , Earle Bridget
Published: February 2017

169

Background: North Shore University Hospital (NSUH) in Manhasset, NY has a thriving in-patient palliative medicine consult service and a 10 bed palliative care suite (PCS). The PCS specializes in managing and treating symptoms as well as the psycho-social, interpersonal and emotional needs of our patients and families. Approximately 80% of the admitted patients expire on the unit. This high rate of patient expiration presents a unique challenge for staff working in this setting. In order to promote self-care and prevent burnout we implemented a yoga program for the nurses and practitioners in the PCS. Our goal was to assess the effectiveness of the yoga program on staff well-being and perceptions on the unit. Methods: We started with an evidence based literature search to validate the high amount of burnout in the clinical setting amongst staff and the benefits of yoga on reducing stress and promoting self-care. A fellow nurse certified yoga instructor was identified to run each session. Participation waivers were obtained from all staff. The yoga program started in June 2013 once to twice weekly in the PCS. All participants were surveyed to evaluate compassion fatigue, burnout and perception of organizational involvement using the professional quality of life scale (ProQOL). Results: There were a total of 23 subjects; 13 (56.52%) participated in yoga and 10 (43.48%) did not. Most of the participants were female and registered nurses. Results of the ProQOL showed no significant difference in compassion fatigue but the majority of subjects reported high perception of organizational involvement from their managers after the program was implemented. Conclusions: The program was feasible, of low cost and sustainable although we did face some challenges. It further identified the value of support from management to improve practitioner self-care and burnout. Our future plans include, assessing effectiveness on a larger scale, offering yoga to patients and family and continuing to implement the project on a more structured basis in the PCS.
Palliative care in a Dutch hospital: Developing a digital care pathway for palliative care.
Authors: Van Der Padt-Pruijsten Annemieke , Oostergo Tanja , Van Der Rijt Carin C. D. , van der Heide Agnes , Leys Rineke
Published: February 2017

17

Background: Awareness is growing that palliative care is an important part in the hospital. It is aimed to improve the quality of life of patients and their relatives in the end-stage of a disease by a multidimensional approach. Prior to the development and implementation of a digital Care Pathway for Palliative Care, we wanted to map the palliative care process during the last hospitalization prior to death of patients with malignancies. Methods: We studied the medical files of patients who died in the period 1 July 2011 – 1 July 2012 within six months after having been admitted to the Department of Oncology and Lung diseases in a general hospital. A checklist was used to collect data about the patients’ diagnosis; the care that was provided during their last stay in the hospital; and about characteristics of the dying process. Results: In total 149 medical records were examined. Most of the patients (78%) were admitted because of complications or progression of the disease. During their last hospitalization, 90% of the patients underwent radiologic tests and 97% underwent blood tests. Furthermore, 38% of the patients received chemotherapy. Of all patients, 55% died during their last stay in the hospital. Medical files contained limited information about the care process: 18% contained information about provision of information to the general practitioner (GP) during admission, 78% contained reports of bad-news conversations. In 36%, the patient’s preference concerning their place of death was unknown. Further, there was no optimal communication with the GP after the patient had died in the hospital; 87% of the GP’s were informed. Conclusions: Palliative care in the hospital was found to involve suboptimal communication on several important topics. A structured medical file to guide palliative care may contribute to improvement of the care process. We are now evaluating the effects of a digital Care Pathway for Palliative Care, that includes ‘marking’ of the palliative phase of a disease and supports adequate communication, advanced care planning, multidisciplinary cooperation and continuity of care.
Concordance with the ASCO Provisional Clinical Opinion on the integration of palliative care into standard oncology care in Ontario.
Authors: Zwicker Victoria , Forster Katharina , Gollnow Angelika , Liu Amy , Sun Jingxian , Tabing Reena , Tyrrell Ashley , Urowitz Sara , Wentlandt Kirsten
Published: February 2017

170

Background: In 2012, ASCO released a Provisional Clinical Opinion for patients with stage IV non-small cell lung cancer (NSCLC) and the need for integration of palliative care services concurrent with standard treatment from the time of diagnosis. To understand if this recommendation is being followed in Ontario, provincial administrative data was used to explore concordance. Methods: Various aspects of concordance were considered including: whether and when in the treatment trajectory patients received palliative care, and how much care was received. For Phase 1 of the analysis, a provincial database of outpatient cancer care was used to identify services received within Ontario’s regional cancer centers (RCCs) and select partner hospitals. The Ontario Cancer Registry and Staging databases were used to identify the patient cohort. The cohort included patients diagnosed with stage IV NSCLC between January 1, 2012 and December 31, 2013. Results: Phase 1 results indicate that 41% of patients received palliative and/or psychosocial oncology care at the RCC or partner hospital after diagnosis. Those receiving palliative care first received services an average of 148 days after diagnosis. See Table below for detailed results. Conclusions: A growing body of literature has identified the benefits of concurrent palliative care. Knowing whether these services are being provided for the NSCLC population is a promising start to understanding and improving the delivery of palliative care in Ontario. Initial results suggest that there is a need for quality improvement in this area. Future phases will expand the analysis to include services received in additional settings such as hospitals and community. [Table: see text]
Palliative care research skill development needs: Lessons from the Palliative Care Research Cooperative Group (PCRC).
Authors: Ritchie Christine , Abernethy Amy P , Aldridge Melissa , Morrison R. Sean , Kutner Jean
Published: February 2017

174

Background: The field of palliative care (PC) has grown substantially over the past decade. PC research has not kept pace, however. One contributing factor is the paucity of clinical investigators equipped to conduct rigorous PC studies, especially multisite studies focused on interventions, dissemination and implementation. A core mission of the Palliative Care Research Cooperative (PCRC) is to enhance investigator capacity to conduct applied patient/caregiver-centered research. Methods: The PCRC Investigator Development Center (IDC) performed two needs assessments in 2015: 1) PCRC methodologic Core Directors; and 2) a subset of PCRC junior investigators. Results: Through these two assessments, PCRC identified the following knowledge/skills gaps in planning and implementing multisite clinical trials and implementation research: basic principles of clinical trials, nuts and bolts of multisite clinical trials, special considerations in behavioral and pragmatic clinical trials, testing treatment efficacy vs testing treatment effectiveness, selection of endpoints and measurement tools, recruitment and adherence issues unique to palliative care populations, data safety monitoring, budgeting and development of protocols/training for multi-site trials. These knowledge/skills gaps were identified by junior investigators as well as by senior investigators whose prior experience is primarily with single-site studies or secondary data analyses. Conclusions: Advancement of PC research requires upskilling of investigators n conduct of multisite studies. The PCRC is partnering with the National Palliative Care Research Center (NPCRC) to make available a range of investigator development resources, including one-on-one mentoring, grant review support, webinars and palliative care research boot camps.
A cross-sectional view of radiation fractionation schemes used for painful bone metastases (PBM) cases within the Veterans Health Administration Radiation Oncology Centers.
Authors: Dawson George Anthony , Glushko Ignat , Hagan Michael Philip
Published: February 2017

177

Background: Though the use of single fraction (SF) radiotherapy in the treatment of PBM is an integral component of frontline palliative radiotherapy in Canada and Europe ((Popovic - Radiotherapy and Oncology 111 (2014) 11–17), its use in the United States is only now gaining clinical acceptance. Recently, VHA Radiation Oncologists reported that roughly 76% offer SF to patients with a limited life expectancy (J Palliat Med. 2014 Nov;17(11):1221-5). In this cross-sectional report, we examine the actual dose fractionation schemes used for PBM cases by VHA Radiation Oncologists. Methods: METHOD: An electronic request was sent to 38 of 39 active VHA RO centers asking them to provide the radiation dose fractionation scheme used in the last 10 of their cases of PBM - (International Classification of Diseases (ICD) 198.5 - secondary malignancy of bone and or bone marrow). The study period: 03/01/2015 to 03/16/2015; Response rate: 100%. Data was provided for 382 cases . The survey results were divided by regions, and the 18 Veterans Integrated Service Networks (VISN) w/ VHA RO Centers. Results: RESULTS: According to the 382 cases analyzed, the top 3 fractionation schemes used were: 1st 300cGy x 10 (169); 2nd 800cGy x 1 (69); 3rd 400cGy x5 (63). Overall, SFRT was used in 18% of cases reviewed. There was, however, substantial variation across Veterans Health Administration. While radiation oncology practices in four Veterans Integrated Service Networks (VISN) used SFRT in 50% or more of their reported cases, practices in seven VISNs used SFRT in only 10% or fewer cases. Single fractions and Hypofractionation (3-7) was more common, comprising 45% of the cases. Conclusions: Compared to prior published data, these results suggest that in addition to our previously reported wide availability of hypofractionation for Veterans receiving palliation, actual increased use of Single Fraction and Hypofractionated radiotherapy for PBM is now common within the VHA. VHA RO are using SFRT per the ASTRO 2013 Choosing Wisely Campaign. [Table: see text]
Effects of the education program for patients with cancer pain.
Authors: Koh Su-Jin , Keam Bhumsuk , Seo Jeong Ju
Published: February 2017

193

Background: Caner pain is prevalent, burdensome, and undertreated. Barriers to good cancer pain control exist within patients on lack of knowledge or poor attitudes towards pain and opioid analgesics. The objective of this study was to test the effects of an education program on reducing barriers to pain management in oncology. Methods: Participants completed baseline assessments and were randomly allocated to receive an education program or not in addition to standard care. Education materials for the pain management program included the ‘Guideline on cancer pain management for patients’. The average education time took basically 30 minutes, and CRNs implemented the education program using a booklet for an individual patient. Outcome measures at one week included the Barriers Questionnaire (BQ), Brief Pain Inventory. Adherence of analgesia and daily activity score were assessed. Results: 176 participants were recruited from 5 sites over 3 months. Mean average pain and worst pain score (NRS) improved significantly in patients receiving education program 1.40 and 1.61. The addiction subscale of the BQ score was improved by 1.95 (pre: 3.39, post: 1.44, p < 0.001) for participants receiving pain education. In terms of administration of short-acting analgesics due to breakthrough pain, inpatients showed no large difference before/after education in the use of short-acting analgesics but outpatients exhibited an increase from 25.5% before education to 73.5% after education and the difference was statistically significant. Conclusions: A cancer pain education was effective in reducing patient's barriers to pain management, improving pain score and daily activity score of cancer patients, especially using short-acting analgesics for breakthrough pain control in outpatients.
Use of medical cannabis to reduce pain and improve quality of life in cancer patients.
Authors: Cudmore Jessica , Daeninck Paul Joseph
Published: February 2017

198

Background: Early attention to pain and symptoms in those with cancer improves both quality of life and survival. Opioid medications are the mainstay treatment of cancer-related pain. Cannabinoids are increasingly used as adjunctive treatments for cancer pain, but clinical evidence supporting their use as an “opioid sparing agent” or to improve quality of life is as yet unknown. Our study sought to determine if the addition of cannabinoids (medical cannabis) resulted in the reduction of the average opioid dose required for pain control, and improve self-reported quality of life indices. Methods: A retrospective chart review of cancer patients followed in our CCMB Pain and Symptom Clinic was conducted. Inclusion criteria: age over 18 years and formal enrollment in Health Canada’s Marihuana for Medical Purposes (MMPR) program (n = 24). Average dose of opioids were calculated in milligrams of morphine equivalent (ME) per day at the last documented visit prior to enrolment in the MMPR and then at the subsequent clinic visit. Averages of self-reported ESAS scores (pain, tiredness, drowsiness, nausea, appetite, depression, anxiety, sense of wellbeing) were calculated for the same visits. Statistical analysis using the paired student’s t-test compared means and determined the significance of any changes. Results: Following enrolment in the MMPR, the average opioid dose decreased by 70.375mg of MEs (p = 0.29). Self-reported ratings (10-point Likert scale) in pain (0.75, p = 0.23), tiredness (0.58, p = 0.21), drowsiness (1.125, p = 0.04), nausea (1.125, p = 0.04), appetite (1.42, p = 0.04), depression (1.29, p = 0.02) and anxiety (1.58, p = 0.004) improved after enrolment. Sense of wellbeing ratings did not change. Conclusions: Patients with cancer pain benefited from the addition of cannabinoids. The average opioid dose decreased following access to medical cannabis. Self-reported ratings of several quality of life indicators showed statistically significant improvement. Our study shows a signal that cannabinoids may reduce cancer patients’ reliance on opioids to control pain. Further prospective controlled studies are needed to further elucidate the role of cannabinoids in the treatment of cancer pain.
Prevalence of vitamin D deficiency among palliative care cancer outpatients: Prospective analysis of 347 cases of single individual medical practice.
Authors: Wojtacki Janusz , Labuc Agnieszka , Banach Piotr
Published: February 2017

204

Background: In spite of the fact that cancer patients under palliative care represent the group of high risk for vitamin D deficiency (e.g. changed nutritional patterns and UV exposure), data reporting vitamin D levels in palliative care setting are rather scarce. Methods: Between Jan-02/2014 and June-20/2015 circulating 25-hydroxyvitamin-D (25-OH-D) levels were analyzed in 76% consecutive patients’ samples of a single individual cancer practice located in Gdansk, Poland. Three hundred forty seven patients (female: 72.5%, median age 64, range: 23-89 years; breast cancer: 57.8%, colon cancer 27.7%) were admitted for palliative care due to: disseminated cancer (18%), side effects of anticancer therapy (56.6%) or symptom control in non-cancer diseases (24.5%). Results of fast 25-OH-D blood tests were correlated with selected clinical factors. Results: The median 25-OH-D level of all our cohort patients was 15.85 ng/mL (range: 0.40 – 62.00 ng/mL); 65.0% of subjects were vitamin D deficient (25-OH-D < 20 ng/mL) and 23.5% insufficient (20-30 ng/mL); only 3.30% patients were taking vitamin D supplements before they entered the study. The univariate analysis identified the following risk factors for inadequate 25-OH-D levels: active cancer disease (median 25-OH-D: 12.50 ng/mL versus 17.86 ng/mL in patients without evidence of disease, p < 0.001) and current glucocorticoids use (at least 14 days within the last month: 11.58 ng/mL versus 17.12 ng/mL in glucocorticoids nonusers; p < 0.01). Age, gender, body mass index values, primary cancer location, dominant metastatic site and higher antibiotics use did not influence 25-OH-D levels. Conclusions: 1) Low (deficient or insufficient) 25-OH-D serum levels were highly prevalent in palliative cancer care outpatients, mostly in those with clinically active disease and using glucocorticoids; 2) the study will continue to address the correlation between 25-OH-D concentrations and symptom burden as well as the potential feasibility of vitamin D supplementation to improve symptoms management of patients in palliative care setting.
Potentially avoidable hospitalizations in older patients with acute myeloid leukemia (AML).
Authors: El-Jawahri Areej , Keenan Tanya , Abel Gregory Alan , Steensma David P. , LeBlanc Thomas William , Traeger Lara , Fathi Amir Tahmasb , DeAngelo Daniel J. , Wadleigh Martha , Hobbs Gabriela , Amrein Philip C. , Stone Richard M. , Ballen Karen K. , Chen Yi-Bin Albert , Temel Jennifer S.
Published: February 2017

206

Background: Many older adults ( ≥ 60) with AML have a poor prognosis and spend a significant portion of their life from diagnosis until death in the hospital. We examined the reasons for hospitalizations and identified potentially avoidable hospitalizations. Methods: We conducted a retrospective analysis of 200 patients ( ≥ 60) diagnosed with AML between 1/1/2006 and 10/30/2011 at two hospitals in Boston to examine the reasons for hospitalizations during treatment. Practicing physicians used a consensus-driven medical record review process to identify primary reason for each hospitalization and categorize it as “potentially avoidable” or “not avoidable” based on a novel adaptation of the Graham’s criteria for potentially avoidable hospital admissions. We compared the rate of potentially avoidable hospitalization between older patients receiving intensive chemotherapy (n = 124) versus non-intensive chemotherapy (n = 76) using Fisher’s Exact test. Results: We evaluated 627 hospitalizations after the diagnosis of AML in 200 unique patients. The median age was 69 years [range 60-90] and the median number of hospitalizations was 4.0 [range 0-18]. 33.2% of patients underwent stem cell transplantation. The most common primary reasons for hospitalizations were: fever/infection (38.3%), planned hospitalizations for chemotherapy or transplantation (35.9%), and uncontrolled symptoms (10.5%). We identified 108/627 hospitalizations (17.2%) as potentially avoidable. Among potentially avoidable hospitalizations, 40.7% were due to premature hospital discharge, 22.2% could have been managed in the outpatient setting, 13.9% failed to have timely outpatient follow-up, and 13% were due to patients’ medication non-adherence. There were no differences in potentially avoidable hospitalizations between patients receiving intensive vs. non-intensive chemotherapy (16.9% vs. 17.8%, P = 0.83). Conclusions: Most hospitalizations in older patients with AML are unavoidable and driven by the illness course and its treatments. However, a minority of hospitalizations is potentially avoidable and should be the focus of future interventions to reduce health care utilization and the burden of AML on this population.
Efficacy and safety of rolapitant for prevention of chemotherapy-induced nausea and vomiting (CINV) in patients (pts) receiving anthracycline-cyclophosphamide (AC)-based chemotherapy.
Authors: Powers Daniel , Schnadig Ian D. , Modiano Manuel R. , Arora Sujata , Schwartzberg Lee Steven
Published: February 2017

208

Background: Rolapitant, a novel NK-1 receptor antagonist, demonstrated efficacy in the prevention of CINV in pts receiving moderately- or highly emetogenic chemotherapy (MEC; HEC). In this post-hoc analysis, we evaluated safety and efficacy outcomes in pts receiving AC-based therapy, now considered HEC. Methods: This double-blind, active-controlled study randomized pts to oral rolapitant 180 mg plus granisetron 2 mg and dexamethasone 20 mg or granisetron/dexamethasone alone (active control). Complete response (CR = no emesis and no use of rescue medication), no emesis, no significant nausea, and time to emesis or rescue medication during overall, acute, and delayed phases and treatment-emergent adverse events (AEs) are presented. Results: 703 pts received AC-based therapy, of which 97% had breast cancer. CR was significantly higher for rolapitant vs. active control for delayed and overall phases in pts receiving AC-based therapy (Table). Time to first emesis or use of rescue medication was significantly longer with rolapitant vs. active control (between-group comparison, p = 0.032); median was not reached in either treatment arm. A significantly greater proportion of pts on rolapitant (73.0%) vs. active control (60.2%) had no emesis during the overall phase (p < 0.001). Rates of no significant nausea were similar for rolapitant (63.7%) and active control (62.4%) in the overall phase (p = 0.728). Treatment-related AEs (TRAEs) during Cycle 1 occurred in 8.7% and 8.8% of pts on rolapitant vs. active control. Most frequent TRAEs were constipation (2.9% vs. 2.7%), fatigue (2.3% vs. 2.2%), and headache (2.3% vs. 3.3%). Conclusions: Rolapitant was superior to active control in preventing CINV during delayed and overall phases after AC-based chemotherapy. The safety profiles of the rolapitant and control arms were similar. These results are consistent with those of the overall pt population in this study. Clinical trial information: NCT01500226. [Table: see text]
A prospective survey of depressive disorder among patients with advanced lung cancer in South China.
Authors: Zhang Li , Sheng Jin , Liu Xia , Yang Yunpeng , Ma Yuxiang , Huang Yan , Zhao Hongyun
Published: February 2017

216

Background: Depression frequently compromises quality of life and prognosis for patients with cancer. However, this psychiatric disorder is often overlooked. This ongoing multi-center investigation was designed to prospectively evaluate the prevalence of depressive disorder in patients with advanced lung cancer in South China. Methods: Patients diagnosed with advanced lung cancer will be screened by two items from the nine-item Personal Health Questionnaire (PHQ-9). For individuals who endorse either item (or both) as occurring for more than half of the time or nearly every day within the last 2 weeks (ie, score of ≥ 2), the remaining 7 items are suggested to be completed. Patients will receice standard palliative chemotherapy according to the preference of oncologists. Demographic variables and clinical information were statistically analyzed. Results: By now, this study have enrolled 97 patients for initial screen, 58 (59.8%) were chemotharapy-naïve. Based on the PHQ-9 questionnaire, the percent of patient suffered from various degree depressive symptomes was 76.3% (74 patients). 51.5% patients (50 cases) were proved with mild depressive symptomes but not met the criteria for depression. Meanwhile, the incidence of moderate or severe depression were separately 17.5% and 7.3%. There were few consistent correlates of depression. Hitherto, 49 patients completed the second investigation after 1or 2 cycles of palliative chemotherapy. In terms of the PHQ-9 score, no statistically significant difference was detected around cytotoxic treatment (mean value: 6.67 and 6.43, p = 0.65). Although the mild depressive symptomes were decreased from 53.1% to 42.9% after palliative chemotherapy, the percent of moderate or severe depression remained the same (17/49, 34.7%). Conclusions: The preliminary result showed that the incidence of depressive disorder among patients with advanced lung cancer may be underestimated. No evidence was found yet to demonstrate the impact of demographic variables on depression. There is unmet need for psychological intervention for advanced lung cancer patients with depressive disorder, especially for those with moderate or severe degree at diagnosis.
Health behaviors and coping among informal caregivers of lung and colorectal cancer survivors: Distribution and interrelationships.
Authors: Kent Erin E. , Litzelman Kristin , Rowland Julia Howe
Published: February 2017

229

Background: Family/informal caregivers play a critical role in the palliative care and support of cancer survivors, yet are at risk of poorer health outcomes than non-caregivers. Self-care, including positive health behaviors and coping, are important for long-term caregiver well-being, and potentially that of care recipients. This study sought to evaluate the distribution of and interrelationships among health behaviors and coping strategies among cancer caregivers. Methods: This study used data from the Cancer Care Outcomes Research & Surveillance Consortium (CanCORS). Caregivers reported by survey their health behaviors, coping, and sociodemographic and caregiving characteristics. Descriptive statistics assessed the distribution of caregivers’ health and coping behaviors, and multivariable linear regressions assessed the associations between health behaviors and coping styles. Results: Many caregivers reported positive health behaviors (i.e., moderate physical activity, adequate sleep, low rates of binge drinking). Caregivers most frequently reported using emotion-focused coping styles (religion, acceptance, positive reframing, emotional support). Caregivers reporting higher levels of physical activity or feeling less well-rested used problem-focused coping styles more frequently (Effect sizes [ES] up to 0.21, p < 0.05) . Those with some physical activity (1-149 minutes/week vs none) scored higher on emotion-focused coping, while drinkers (1+ drink in the past 30 days vs 0) and binge drinkers (5+ drinks in a row vs 0) scored lower on this subscale (ES = 0.16, 0.12, and 0.25; p < 0.05). Caregivers reporting current smoking (ES = 0.21), binge drinking (ES = 0.49), and feeling less well-rested (ES up to 0.48) scored higher on dysfunctional coping (p < 0.05). Conclusions: Caregivers’ health behaviors and coping strategies were interrelated. Interventions targeting both factors concurrently may be particularly efficacious at improving family caregiver self-care, potentially improving caregiving quality and patient-centered palliative care. Future research is needed to design and test such interventions and the potential impact on palliative care.