bluuebunny/crossref_metadata_2025 huggingface dataset:
What’s in the ‘special sauce’ of protocol-driven outpatient palliative care consultations?
Authors: Bagcivan Gulcan , Bakitas Marie , Dionne-Odom J Nicholas , Frost Jennifer , Plunkett Margaret , Lisa A Stephens Lisa A , Bishop Peggy
Published: February 2017

139

Background: Initial outpatient palliative care consultations (OPCC) in clinics are usually requested for uncontrolled symptoms. The purpose of this substudy was to determine the nature of recommendations made in early PC (EPC) protocol-driven OPCC. Methods: Using a standardized tool, we conducted a content analysis on the assessment and plan components of protocol-driven OPCCs. OPCCs were conducted as a component of the ENABLE [Educate, Nurture, Advise, Before Life Ends] RCT (10/2010-9/2013) consisting of an OPCC and 6 structured weekly telephone coaching sessions and monthly follow up either at study entry (early) or 12 weeks later (delayed). We coded OPCCS for 37 specific recommendations, grouped into 3 categories: general, symptom-specific or advance care planning (ACP). Results: Of 207 study participants, 142 (early = 71; delayed=71) had an OPCC; 65 (31%) did not receive OPCC due to unable (n=35), unknown (n=17), and declined (n = 13). OPCC patients were mostly female (51%), married or living with partner (65%), rural-dwelling (66%), high school graduates (54%), white (99%), Catholic (30%), retired (46%), and had GI cancers (44%). Patients who had OPCCs had statistically ↓ CAGE (p = 0.03), ↑rural-dwelling (p = 0.03), and ↓hospice referral (p = 0.03) at baseline. Median OPCC length was 60 minutes (range 15-105). The most frequent general recommendations were for counselling (34%, n = 48) and medication review (30%, n = 43); symptom-specific recommendations were for pain (16%, n = 23), depression (11%, n = 16), and constipation (8%, n = 11); and ACP were for AD completion (20%, n = 29), identifying surrogate (18%, n = 25), and discussion of illness trajectory (17%, n = 24). There were no significant differences in recommendations between early and delayed group (p > 0.05) except hospice discussion was ↑ in delayed patients (p = 0.02). Conclusions: Protocol driven OPCCs for newly diagnosed advanced cancer patients can prospectively address patients’ needs for additional counseling, symptom control and ACP. Future analyses will focus on relationships regarding overall EPC ‘dose’ and longitudinal patient outcomes.
Snapshot of an outpatient supportive care center at a comprehensive cancer center.
Authors: Pimentel Lindsey E , De la Cruz Maxine Grace , Wong Angelique , Castro Debra , Bruera Eduardo
Published: February 2017

145

Background: Integration of Palliative Care (PC) in oncology has been found to improve symptom distress, quality of life and survival in patients with advanced cancer. Early integration is most appropriate in the outpatient (OP) setting. However, most PC services in the U.S. do not have an OP component. Our study aims to provide a snapshot of the type of patients that are referred to this novel setting for the delivery of early PC. Methods: We reviewed a day in the SCC to illustrate the structure and process involved in the delivery of outpatient PC. We highlighted 9 patients seen that day to show the variety of patients, scope of services, and the unique roles that PC interdisciplinary team members perform. Results: 41 patients were seen that day in the SCC: 10 scheduled consults, 22 scheduled follow-ups, 9 (22%) same-day unscheduled patients: 4 follow-ups, 1 consult and 4 nurse triages. There were also 31 telephone encounters. Most patients seen were for routine follow-up and symptom assessment. However, 10 presented with worsening symptoms with one needing hospital admission. 21 patients required additional counseling: 2 for hospice transitioning, 12 for psychosocial distress, 7 for opioid education. PC was delivered predominantly by physicians and nurses with collaboration with our pharmacist, counselors, and case manager. Conclusions: Traditionally, PC has been delivered predominantly to patients with advanced disease and to aid in transition to end of life. In recent years, OP centers have dramatically changed the nature of PC work as in our snapshot. In addition to patients regarded as traditional PC patients, such as those transitioning to end of life, there are now patients who come in soon after arrival to a cancer center requiring specialized care to address a variety of symptom and educational needs, thus requiring adaptation of structure and processes to allow access for frequent follow ups and counseling and flexibility for walk-in visits. Our findings suggest that SCC needs to practice in a very different way which requires certain skills and assessment tools that are not conventionally present in traditional oncology clinic setting. More research is needed to identify the type of patients that would benefit most from a PC referral.
Use of an EMR online portal for communication with cancer patients.
Authors: Siegel Craig Stephen , Spies Vicky , Rodin Miriam B. , Tu Yifan
Published: February 2017

147

Background: Communication with patients about their health care is vital to the physician-patient relationship. This is especially true in oncology where patients receive frequent diagnostic evaluations and their diseases are often active and evolving. In 2009, as part of “meaningful use”, Congress mandated the need to establish an electronic portal for patient communication. We studied factors associated with the use of our online patient portal. Methods: We performed a retrospective chart review of the use of our EMR online portal, MyChart. We assessed whether patients were informed of the existence of the portal and if they had activated and used it. We analyzed whether disparities in age, gender, rural or urban residence, or income impacted patients’ use of this feature. Results: Between January 1, 2014 and December 31, 2015, 1947 patients were seen in the Hematology Oncology Clinic at St. Louis University Hospital. 508 (26.1%) had activated and used MyChart and 1437 (73.9%) had not. Of 1437 patients who had not used MyChart, 110 (7.6%) had not been given the code, 1316 (91.5%) had been given the code but had not activated it, and 13 (0.9%) had declined the code. Patients who activated MyChart were more likely to be less than 65 years old (60.0% vs 40.0% p < .0.0001). Patients who did not activate it were more likely to live in a ZIP code where the median annual income was below the state median, a surrogate for lower income (84.8% vs 15.2%, p < 0.0001). Use of MyChart was not statistically associated with gender or with residence in an urban versus rural location. Conclusions: A large majority of patients in our urban, academic oncology clinic did not access the online communication portal. Use was associated with younger age, and lack of use was associated with residence in a lower income ZIP code. There was no association between use and gender or residence in an urban versus rural location. Future work will attempt to improve provider-patient communication through increasing access to the portal.
Palliative care and health care utilization at the end of life.
Authors: Triplett Daniel P , LeBrett Wendi G , Matsuno Rayna , Hwang Lindsay , Boero Isabel , Roeland Eric , Yeung Heidi , Murphy James Don
Published: February 2017

152

Background: Palliative care’s role in oncology has expanded, but its impact on aggressiveness of care at the end of life has not been characterized at the population level. Methods: This matched retrospective cohort study examined the effect of an encounter with palliative care on healthcare utilization at the end of life among 6,580 Medicare beneficiaries with advanced prostate, breast, lung, or colorectal cancer. We compared healthcare utilization before and after palliative care consultation to a matched non-palliative care cohort. Results: The palliative care cohort had higher rates of healthcare utilization in the 30 days prior to palliative care consult compared to the non-palliative cohort, with higher rates of hospitalization (risk ratio [RR] 3.33; 95% CI 2.87-3.85), invasive procedures (RR 1.75; 95% CI 1.62-1.88), and chemotherapy administration (RR 1.61; 95% CI 1.45-1.78). The opposite pattern emerged in the interval from palliative care consultation through death, where the palliative care cohort had lower rates of hospitalization (RR 0.53; 95% CI 0.44-0.65), invasive procedures (RR 0.52; 95% CI 0.45-0.59), and chemotherapy administration (RR 0.46; 95% CI 0.39-0.53). Patients with early palliative care consultation had larger absolute reductions in healthcare utilization compared to those with palliative care consultation closer to the end of life. Conclusions: This population-based study found that palliative care substantially decreased healthcare utilization among Medicare beneficiaries with advanced cancer. Given the increasing number of elderly patients with advanced cancer, this study emphasizes the importance of early integration of palliative care alongside standard oncologic care.
The evolving radiation therapist role in a multidisciplinary palliative radiotherapy clinic.
Authors: LeGuerrier Bronwen , Huang Fleur , Spence Winter , Rose Brenda , Middleton Jacqueline , Palen Megan , Thavone Kitta , Ravji Shazma , Danielson Brita Lavender , Fairchild Alysa M.
Published: February 2017

158

Background: Radiation therapists (MRTT) have been integrated in varying capacities into outpatient palliative radiotherapy (PRT) services across Canada for nearly two decades. We explored the experience of our centre’s MRTTs who have developed an essential role over nine years, from supporting one half-day PRT clinic per week to five full days of clinical, technical, research, and administrative involvement. Methods: An electronic survey was distributed to all 12 MRTTs who contributed to the PRT program (2007-2016), which was later supplemented by in-person semi-structured interviews. Qualitative analysis of the responses was undertaken to discern common themes. These were contextualized within the operational changes to our multidisciplinary clinical model, from pilot to integrated service. Results: Among seven respondents (range of PRT-specific experience: 1-5 years), five answered all questions. From the narratives, three common themes emerged: responsibilities, challenges, and opportunities. Responsibilities identified included: PRT planning/delivery (cited 13 times), patient assessment (12), multidisciplinary collaboration (MDC) (8), research (8), navigation (7), clinic process innovation (5), administration (5), communication (4), and education (2). Challenges described included: lack of support (cited 10 times), lack of shared understanding (5), high workload (5), pushback from colleagues (3), and inadequate staffing (2). However, opportunities outnumbered challenges, in terms of evolution of involvement in MDC (cited 13 times), patient care (8), increased autonomy (6), professional growth (5), role variation (5), scope of practice expansion (2), and being the team’s key contact for referrals (2). The range of MRTT experiences, responsibilities and challenges encountered reflected specific PRT clinical and operational conditions. Conclusions: As our PRT service model has evolved from short-term pilot to fully integrated departmental service, so has the MRTT role. MRTTs contributing to PRT as part of a MDC model are supportive of advancing non-traditional involvement in the holistic palliative care of patients with advanced cancer.
Referral patterns among patients with metastatic breast cancer in an integrated palliative care program.
Authors: Small Rebecca , Belkora Jeffrey , Majure Melanie Catherine , Chien Amy Jo , Melisko Michelle E. , Rugo Hope S. , Rabow Michael W.
Published: February 2017

163

Background: ASCO recommends palliative care (PC) concurrently with oncologic treatment for patients with metastatic disease and there is emerging data about the benefits of early PC. However, little is known about referral patterns to specialty PC among patients who die of metastatic breast cancer. Methods: After years of offering a stand-alone outpatient PC consult service in our comprehensive cancer center, we established an integrated PC program in breast oncology (the “Advanced Breast Cancer (ABC) Program”) with a care coordinator, PC physician, and co-location with oncology. Among patients who died, we analyzed referral patterns, program participation, and end-of-life quality outcomes from October 2014 through May 2015. Results: 38 of 108 patients (35.2%) referred to and seen in ABC died, with an average of 2.9 PC visits (range 1-17) and 7 months (range 0-20) between referral and death. Reasons for referral among ABC patients who died included: symptom management (15 patients, 39.5%); goals of care discussions (12, 31.6%); psychosocial support (5, 13.2%); discharge referral from the inpatient PC team (4, 10.5%); and new diagnosis of metastatic disease (3, 7.9%). At the time of referral, average time since metastatic diagnosis was 23.6 months (range: 0-106); 10 patients (26.3%) had received > 3 lines of treatment. 15 referred patients (13.9%) died but were not seen by ABC: of those, 6 initiated hospice before they could be seen; 5 initially declined or deferred the referral but then were too sick to be seen in clinic by the time they agreed; and 4 were unwilling to accept extra appointments or did not follow-up to repeated outreach. 24 ABC patients who died (63.2%) were seen early (> 90 days before death), whereas in the year prior to the ABC clinic, among patients who died, only 11 of 44 (25%) who had received PC consultation received it early. 19 of 33 (57.6%) ABC patients for whom data was available utilized hospice, with only 2 (5.3%) using hospice < 3 days. Conclusions: Embedding and integrating a PC practice in breast oncology resulted in patients being seen earlier. Future efforts should be directed at further increases in earlier referrals by oncologists and in facilitating patient acceptance of early referrals.
The I-ONE trial: Integrative oncology education for patient navigators—A randomized pilot trial of web-based distance learning with or without small group retreat.
Authors: Mumber Matthew P. , Beard Karen , Liu Yuan , Kerber Alice S.
Published: February 2017

171

Background: One of the major barriers to implementation of an integrative oncology (IO) approach is appropriately trained providers. This trial investigated the effectiveness of a mixed method educational program versus web based learning only for oncology patient navigators relative to knowledge and application of IO modalities. Methods: Patient navigators were randomized 1:1 to Web based education only (WEB) vs. WEB plus residential retreat (WEB+R). The trial was conducted as a randomized, two-group, pre-test/post-test design with 4 repeated measures. The primary study outcomes were knowledge and attitudinal beliefs about the perceived efficacy of IO approaches, as well as clinical and personal practices related to IO. Results: 24 patient navigators from varied educational backgrounds and practice settings were randomized to WEB vs. WEB+R. Referrals to complementary therapies increased by 104% immediately after training (p = .013) and by 77.4% 30 days out. (p = .013). There was a statistically significant increase in attitudinal beliefs about the perceived efficacy of IO approaches as measured by the Integrative Medicine Attitude Questionnaire (IMAQ) from baseline to posttest (p = .013). There were no significantly different values between randomized groups in any of the areas surveyed, however internal group pre and post test comparisons had multiple statistically significant improvements in the WEB + R group while there were no such changes in the WEB group, suggesting a trend toward increased educational efficacy for WEB + R that was likely the major driver of entire group educational improvements. Conclusions: Both Web based and Web based plus small group retreat programs were found to be effective in increasing clinical application and attitudinal beliefs about IO in patient navigators. There was a trend toward improved educational efficacy with WEB +R likely related to shared group and personal experience. As IO approaches become part of standard of care, mixed method online plus small group retreat programs would be useful for widespread dissemination of medical knowledge and increased clinical application of IO approaches.
Thirty-day mortality rate in oncology patients treated with palliative radiotherapy.
Authors: Bingham Brian Stewart , Dvorak Tomas , Morris Christopher G. , Yeung Anamaria R
Published: February 2017

172

Background: Thirty-day mortality is a well-established metric for surgical specialties, but there are limited data available for 30-day mortality after radiation therapy. Our aim was to specifically identify the 30-day mortality of patients treated with palliative radiotherapy for the purposes of establishing a baseline to improve upon. Methods: We retrospectively reviewed the medical records of all patients treated with external-beam radiotherapy (EBRT) from January 1, 2012, to December 31, 2012, who died within 30 days of their last delivered radiation fraction. Patient age, sex, primary disease site, treatment site, fractions planned, and fractions delivered were recorded. Among all patients treated with palliative intent, age (> 70 and < 70 years) and sex were assessed for increased risk of 30-day mortality using a Fisher’s Exact test. Results: Of the 877 patients who received EBRT, 262 were treated palliatively and 615 were treated with curative intent. Of the 262 patients treated palliatively, 33 died within 30 days of the last delivered fraction, resulting in a palliative 30-day mortality rate of 12.6%. Of these 33 patients, the most common primary disease sites were lung (15%), pancreas (12%), and head/neck (12%), and the most common treatment sites were metastases to bone (37%) and brain (24%). In cases of palliative 30-day mortality, 10 or fewer fractions were prescribed 90% of the time and 83% of patients received more than half of their prescribed fractions. Among all patients treated with palliative intent, age (p = 0.0576) and sex (p = 0.5572) were not significantly associated with higher rates of 30-day mortality. Conclusions: We have established a baseline palliative radiation 30-day mortality rate at 12.6%, with the majority of patients receiving less than or equal to 10 radiation fractions and completing most if not all of their intended fractions. This analysis suggests institutional practices that are in line with other published patterns of care, and illustrates how clinical characteristics and 30-day mortality rate can be used to better understand palliative radiotherapy outcomes at a single treatment center.
Predicting hospital readmissions in the oncology population.
Authors: Thirlwell Sarah , Donovan Kristine A. , Turney Mary , Emnett C. Edward , Lamoreaux Amber , Portman Diane G.
Published: February 2017

177

Background: The 30-day readmission rate is established as an important indicator of quality of care. The LACE index is commonly used in the general medical setting to predict readmission but its ability to predict readmission with sensitivity and specificity in the oncology population has not yet been examined. At our cancer center, palliative care (PC) consultation is associated with an increased risk for readmission but it is not an element in the LACE index. Methods: We sought to characterize the operating characteristics of the LACE Index using receiver operating characteristics analyses to predict unplanned readmissions to our cancer center over a 6-week period beginning March 2016. Data was gathered from chart review to calculate a total LACE score for each unplanned admission. Logistic regression was used to examine the individual components of the LACE index and whether a PC consult improved the performance of the index. Results: A total of 329 patients with unplanned admissions were included. Fifty-nine (17.9%) were readmitted within 30 days of discharge. There was no difference between the median LACE scores of those readmitted compared to those who were not (Md = 10.0; p = .93). Receiver operating characteristic (ROC) curve analyses of LACE scores yielded an area under the curve estimate relative to 30-day readmissions of .45 indicative of poor overall accuracy. ROC analyses also showed that the previously established LACE cutoff score of 10 had sensitivity of .54 and specificity of .57 relative to readmissions. The positive predictive value was .81 and the negative predictive value was .18. In logistic regression analysis, only direct referral center/emergency department visits were an independent predictor of readmission, with a c-statistics of .64 for readmission. The inclusion of a PC consult did not improve the performance of the index. Conclusions: The LACE Index performed poorly in predicting 30-day readmission in the oncology setting; the inclusion of whether a PC consult took place did not improve the index’s utility. Further research is required to create a new tool or enhance existing indices to predict readmission in the oncology population.
Palliative treatment directives for bone metastases: A quality-directed approach to guiding institutional practice.
Authors: Puckett Lindsay , Lee Lucille , Zuvic Petrina , Zhang Isabella Bingchan , Potters Louis , Bloom Beatrice
Published: February 2017

188

Background: The efficacy of single fraction (fx) radiation treatment (RT) has proven to have equipoise for palliation of bone metastases when compared to courses of 10 fx or more. Despite these data, there has been a slow adoption of this practice in the US and worldwide. Examination of our multicenter practice from 2004 - 2016 showed that single fx RT utilization has remained at 17% and hypofractionationed (HFX) courses (1 or 5 fx) have remained at 71% since 2009. We hypothesized that evidence-based, treatment-guiding directives could improve HFX utilization in this population. Methods: Institutionally, palliative bone metastasis treatments are routinely tracked by a Quality Assurance committee. In 2/2016, two consensus-driven and evidence-based clinical directives were created within our electronic health system for use with either simple or complicated bone metastasis, irrespective of primary histology. The simple and complex directives had default prescriptions of 8 Gy/1fx or 20 Gy/5fx, respectively. The directives were reviewed with physician staff to improve compliance; directives were allowed to be edited at the physician’s discretion if an alternative fx was indicated. The chi-square test was used for analysis. Results: From 1/2009-5/2016, there were 1,781 treatment courses of palliative external beam RT. Following implementation in 2/2016, the new clinical directives were used for 96% of cases and were modified in 12 cases (n = 72). Single fx use increased from 17% to 36% among palliative bone metastasis treatments (p ≤ 0.001) and HFX (1 or 5 fx) utilization increased from 71% to 92% compared to other fractionation schemes (10 fx or other) (p = 0.001). Conclusions: The institution-wide adoption of evidence-based, treatment directives proved to be a straightforward and successful intervention which allowed for rapid adoption and increased utilization of the standard of care. Our early data suggests that this may be a useful approach in the setting of reticence to new treatment paradigms. Further examination of evidence based directives is warranted to address issues of overtreatment in palliation and in standardizing oncologic care.
Yoga program for patients with brain tumors undergoing radiotherapy (XRT) and their family caregivers.
Authors: Milbury Kathrin , Mallaiah Smith , Mahajan Anita , Armstrong Terri S. , Weathers Shiao-Pei S. , Moss Kathryn E , Goktepe Nazli , Spelman Amy , Cohen Lorenzo
Published: February 2017

200

Background: The role of behavioral medicine in the symptom management of glioma patients is largely unknown. Moreover, although the literature revealed that family caregivers are at risk of physical and psychological burden, the needs of caregivers generally remain unaddressed. The purpose of this study was to establish feasibility and preliminary efficacy of a couple-based Yoga (CBY) intervention in glioma patients and their caregivers targeting QOL outcomes. Methods: This small, single-arm pilot trial included adults with low and high grade glioma undergoing XRT and their family caregivers. Dyads participated in a 12-session CBY program focusing on breathing exercises, gentle movements and guided meditations. We tracked feasibility data and assessed levels of cancer-related symptoms (MDASI), depressive symptoms (CES-D), fatigue (BFI), sleep disturbances (PSQI), spiritual well-being (FACT-SP) and overall mental and physical QOL (SF-36) at baseline and post-CBY, which was at the end of XRT. Participants also completed program evaluations. Results: We approached 7 dyads of which 5 (71%) consented. All participants completed all 12 sessions and pre/post assessments. All patients (mean age: 52 yrs., 80% female, 80% high grade) and caregivers (mean age: 58 yrs., 60% female, 60% spouses) indicated that they perceived benefit from the program. Paired t-tests revealed a marginally significant, yet clinically meaningful, decrease in patient’s cancer symptoms (t = 2.32, p = .08; MDASI mean; 32.06 vs.18.80). There were clinically significant reductions in patient sleep disturbances (PSQI mean: 10.75 vs. 8.00) and improvements in patient and caregiver mental QOL (MCS of SF-36 mean: 42.35 vs 52.34 and 45.14 vs 51.43, respectively). All other means were generally in the expected direction. Conclusions: This novel supportive care program appears to be safe, feasible, acceptable, and subjectively useful for glioma patients and their caregivers. Although the trial did not have a control group, it is notable that multiple symptom outcomes improved when they would normally have been expected to deteriorate over the course of XRT. We are currently conducting a randomized controlled trial to examine treatment efficacy. Clinical trial information: 2015-01124.
The requirement of fentanyl patch in terminally ill patients with cancer.
Authors: Shimada Naoki , Watanabe Aya , Ishiki Hiroto , Chiba Tsukuru , Kinkawa Junya , Watanabe Chie , Ariyoshi Keisuke , Nojima Masanori , Iwase Satoru , Tojo Arinobu
Published: February 2017

202

Background: Cancer pain is the most important problem to overcome in terminally ill cancer patients (TICPs). Recently, the fentanyl patch (FP) has been widely used for the treatment of cancer pain. However, the FP requirement largely varies in patients. The purpose of this study was to identify the determinants of the FP requirement in TICPs and propose effective pain relief using a FP. Methods: In a retrospective chart review, we investigated cancer patients who were admitted in our hospital from April 2012 to July 2015 and used FP until their deaths. We examined the time course of FP use in TICPs until death. We used descriptive statistics and a mixed effect model. The primary endpoint of this study was the final dose of FP use (FDFP). Results: Eighty patients were included the analysis. The clinical characteristics were as follows: age (median, range): 64.5 (29-88) years; male/female ratio: 40/40; primary tumor sites: pancreas (n = 33), digestive tract (n = 12), liver and bile duct (n = 7), ovary and uterus (n = 6), hematologic (n = 5), lung (n = 4), head and neck (n = 4), breast (n = 3), and other (n = 6). FDFP was inversely correlated with age (R = -0.272, P < 0.05; Spearman test). The FDFP (mean ± SD) administered in the patients was 3.06 ± 3.20 mg/day (Male/Female: 3.83 ± 4.06/2.29 ± 1.81 mg/day). The FDFP was 4.36 ± 4.32/2.15 ± 1.64 mg/day in patients with/without pancreatic cancer. FDFP was significantly higher in male than in female patients (P < 0.05; student’s t test), and also significantly higher in patients with pancreatic cancer than in patients without pancreatic cancer (P < 0.005; student’s t test). In pancreatic cancer patients, the FP adjustments were more frequent in the last 60 days of life than in patients with other malignancies (P for interaction < 0.001; mixed effect model). Conclusions: We found that younger age, male sex, and pancreatic cancer were risk factors for higher requirement of FP in TICPs. TICPs with pancreatic cancer in particular required more frequent adjustment of FP near death. We should consider quick titration of fentanyl in patients with pancreatic cancer because the pain-relieving action of FP requires time.
Effects of high-dose Asian ginseng (Panax ginseng) to improve cancer-related fatigue: Results of a double-blind, placebo-controlled randomized controlled trial.
Authors: Yennu Sriram , Tannir Nizar M. , Williams Janet L. , Hess Kenneth R. , Frisbee-Hume Susan , House Helen L , Fossella Frank V. , Lim Zita Dubauskas , Lopez Gabriel , Reddy Akhila Sunkepally , Azhar Ahsan , Wong Angelique , Patel Sunil M. , Kaseb Ahmed Omar , Hwu Wen-Jen , Lu Zhanni , Cohen Lorenzo , Bruera Eduardo
Published: February 2017

209

Background: Cancer related fatigue (CRF) is the most common and disabling symptom in cancer.Panax ginseng extract (PG) is frequently used as a nutraceutical treatment for fatigue. There are no well-powered placebo-controlled trials that used validated CRF outcome measures to investigate of PG effects in cancer patients. The primary objective of this trial was to evaluate the effects oral PG versus Placebo (PL) for CRF. Methods: Patients with cancer fatigue ≥ 4/10 on Edmonton Symptom Assessment Scale (ESAS) were eligible. Patients were randomized to either 400mg of standardized PG or matching PL orally twice a day for 28 days. The primary endpoint was change in the Functional Assessment of Chronic Illness-Fatigue (FACIT-F) fatigue subscale from baseline to Day 28. Secondary outcomes were Functional Assessment of Cancer Therapy-General (FACT-G), Hospital Anxiety and Depression Scale (HADS), and ESAS. Results: Total evaluable patients were 112 (56 for PG and PL groups). No significant differences in baseline characteristics between the two groups except cancer type (p = 0.002). There was significant improvement in FACIT fatigue and ESAS fatigue scores in PG and PL groups at Day 15 and Day 29. The mean (SD) of FACIT-F fatigue scores at baseline, Day 15, and Day 29 were 22.6 (10.4), 29.8(10.7), 30.1 (11.6) and 23.8 (9.1), 30.0 (10.1), 30.4 (11.6) for PG and PL respectively. Mean (SD) improvement in the FACIT-F subscale at Day 29 was not significantly different in PG than in the PL group [7.5 (12.7) vs 6.5 (9.9), P = 0.67]. Mean (SD) improvement in the ESAS fatigue, FACT-G, and HADS at Day 29 were also not significantly different in PG than in the PL group. In a multiple linear model analysis, the change in FACIT-F fatigue from Day 0 to Day 29 was negatively correlated with baseline FACIT-F fatigue (p = 0.0005), baseline HADS score (p = 0.032), and male gender (p = 0.023). There were a significantly higher number of any grade of toxicities in PL group than in PG group (33/62 vs. 28/64, p = 0.024). Conclusions: Both PG and Placebo result in a significant improvement in CRF at Day 15 and Day 29. PG was not significantly superior to placebo after 4 weeks of treatment. Further studies are needed. Clinical trial information: NCT01375114.
Efficacy and safety of methadone in the treatment of pain in palliative care patients with cancer: The EQUIMETH2 national, randomized, open, phase III study.
Authors: Poulain Philippe , Berleur Marie Pierre , Lefki Shimsi , Lefebvre Kunt Daniele , Serra Eric , Chvetzoff Gisele , Derniaux Alain , Tremellat Flora , Filbet Marilène , Simon Anna , Dang Vu Bich , Guillaume Cyril
Published: February 2017

212

Background: Methadone is used more and more as a second-line treatment for refractory cancer pain in palliative care patients. Methods: The study aimed to compare the effect of two methadone titration methods (Stop and Go vs progressive titration) in 146 palliative care cancer patients with pain inadequately relieved or intolerant to level 3 opioids. The primary endpoint was the rate of success/failure at Day 4 defined by pain relief (reduction of at least two points of the numerical scale (0 - 10) AND a pain score < 5 for 2 consecutive days) AND no overdose (Rudkin scale ≥ 3 AND respiratory rate < 8/min). Results: Pain was nociceptive in 16% and mixed in 84%. 85% of the patients had breakthrough pain. Half received oxycodone, 1/5 fentanyl, 1/5 morphine and < 10% hydromorphone. Reasons for switching were lack of efficacy isolated (56%), or with intolerance to previous opioid (38%). More than 2/3 of the patients reached a pain score < 5 for two days at D4, adequate pain relief was obtained in 80% of the patients (median of 3 days in both groups (p = 0.12)) and lasted until D56. The rate of success/failure was about 40% at D4 with no difference between the two methods. Overdoses defined as respiratory rate < 8/min were observed in 13.2% patients throughout the study with no difference between groups. 9 required naloxone. The two methods were equally considered easy by about 60% of the clinicians. Conclusions: Methadone is an effective and sustainable second-line alternative opioid in the treatment of cancer pain in palliative care patients inadequately relieved or intolerant to level 3 opioids. The two methods of titration of methadone are comparable in terms of efficacy, safety and ease of use.
Association between anti-cholinergic burden and delirium among patients with advanced cancer referred to a palliative care consult service.
Authors: De La Cruz Maxine Grace Jaucian , Baidoo Joseph , Balankari Vishidha Reddy , Waletich-Flemming Jessica Marie , Delgado-Guay Marvin , Wu Jimin , Liu Diane D , Bruera Eduardo
Published: February 2017

213

Background: Delirium occurs in about 45-60% hospitalized patients and 80-85% at the end of life. Predisposing factors include anti-cholinergic medications as is often cited in the geriatric literature. Our study aimed to demonstrate the association of anti-cholinergic burden and delirium in patients with advanced cancer. Methods: Retrospective review of 775 consecutive patients seen by the palliative care inpatient consult team. Demographic data, MDAS, ECOG, and anti-cholinergic drugs were determined. Anticholinergic burden was measured using the anticholinergic drug scale (ADS), anticholinergic risk scale (ARS), and anticholinergic burden scale (ACB). Patients with delirium and those who did not develop delirium were compared. Association between delirium and anticholinergic use were analyzed using Chi-squared test, univariate and multivariate logistic regression models. Results: 270/775 (35%) had delirium at the time of consult. Median age was 58 years. The median total of anticholinergic drugs in both groups was 6. Anticholinergic burden using the ADS (median 2 vs. 3; p = 0.09) and ARS (median 0 vs. 1; p = 0.75) was not different in both groups. ACB score were significantly different in both groups (median 1 vs 2; p = 0.0006). Univariate analysis showed hematologic malignancy (OR = 1.85, 95%CI: (1.23, 2.77), p 0.0030, poor ECOG, age (OR = 1.03, 95%CI: (1.02, 1.04), p < 0.0001) and ACB score (OR = 1.11, 95%CI: (1.03, 1.21), p 0.0069 to be associated with delirium. In our multivariate model ECOG (OR = 0.25, 95% CI: (0.17, 0.36), p < 0.0001), and age (OR = 1.03, 95% CI: (1.01, 1.04), p < 0.0001) are the only independent covariates significantly associated with the presence of delirium at admission. Conclusions: Our study found that in this younger population with cancer, the total number of anticholinergic drugs and the anticholinergic burden using 3 different scales were not associated with delirium suggesting a different mechanism. Further studies are needed to confirm these findings.
Palliative whole brain radiotherapy: Predictors of prescribing 5 versus 10 fractions.
Authors: Duimering Adele , Baker Sarah , Paulson Kim , Debenham Brock J , Ghosh Sunita , Ma David L , Huang Fleur , Chu Karen P , Severin Diane , Amanie John , Nijjar Tirath , Patel Samir , Wiebe Ericka , Danielson Brita Lavender , LeGuerrier Bronwen , Fairchild Alysa M.
Published: February 2017

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Background: The optimal dose for palliative whole brain radiotherapy (WBRT) continues to be debated. Common regimens include 20 Gy in five and 30 Gy in 10 fractions. We aimed to identify factors associated with WBRT dose schedules, hypothesizing that clinical prediction of survival (CPS) would influence prescribing practice. Methods: Demographic and clinicopathologic data were collected for consecutive patients with brain metastases receiving WBRT through a dedicated palliative radiation oncology clinic. At initial consultation, CPS were prospectively collected from treating radiation oncologists. Karnofsky performance status (KPS) and Mini-Mental Status Examination were available for 88.6% and 75.1%, respectively. Dose fractionation was collected and summary statistics calculated. Parameters were assessed for association with five fraction schedules using binary logistic regression, with odds ratios and 95% CI reported. Results: 193 patients underwent WBRT (N = 102 from 2010-2012; N = 91 from 2013-2014); 38/193 had 48 extracranial sites irradiated concurrently. 46.1% were male, mean age was 64.7 years (SD 11.6), and 63.7% had lung cancer. Median KPS was 70 (range 20-100) and median MMSE score was 27/30 (range 13-30). Median CPS and actual survival were 150 days (range 21-730d) and 96 days (range 11-1029d), respectively. 18.7% received WBRT within 30 days of death. 78.2% (151/193) and 17.6% (34/193) received five and 10 fractions, respectively; 8/193 were prescribed other schedules. On multivariate analysis, patients with KPS ≤ 70 were 5.93 times more likely to have received 5-fractions (95% CI 2.51-14.1; p < 0.0001). Those treated 2010-2012 were less likely to have received 5 fractions (OR 0.28; 95% CI 0.11-0.68; p = 0.005). CPS, age, gender, MMSE, histology, disease extent, and extracranial irradiation were not predictive of WBRT schedule. Conclusions: Patients treated with WBRT with KPS ≤70 and those treated more recently were more likely to receive five fractions. Oncologist CPS was not a statistically significant predictor of schedule in this cohort.
Novel tool utilized as a trigger for advance care planning in hospitalized oncology patients.
Authors: Lincoln Nicole , Rao Sandhya , Sarnacki Diane , Dobie Alexandra , Damus Karla , Gignac Gretchen
Published: February 2017

22

Background: Study Purpose: reduce inpatient oncology readmissions; determine if there is a need to standardize trigger for Advance Care Planning in the inpatient oncology population. Methods: Investigational Quality Improvement Study January-June 2014. Retrospective chart review of oncology readmissions on the BMC Hematology and Oncology service during a 6 month period, January-June 2013 (N = 68). Data abstracted included: demographics (age, race/ethnicity, primary language, education, marital status, ECOG); type and stage of cancer; type of consults (palliative, spiritual, social services, integrative, PT/OT, hospice, visiting nurse). Developed a Severity of Illness Scale for use in the oncology inpatient patients at BMC. Results: Mortality rate within 1 year of discharge: 32.8% (non-elective readmissions) 19/58; mean days to death from readmission discharge: 65 days (range 0-252); 84.2% of those who died had metastatic cancer in index admission; only 37% ever had a palliative care consult placed (all on readmit); only 17% had a documented EOL discussion on index admission; 38.5% of patients had lung CA (22% of all non-elective readmissions). Conclusions: (1) There is a need to standardize triggers to goals of care discussions and access to Palliative Care in the Hematology/Oncology Inpatient Population at this Institution. (2) Readmissions may be reduced with better Advance Care Planning. (3) There is a communication gap amongst interdisciplinary teams in regards to Advance Care Planning at this institution. Currently IRB Approval for use of novel severity of illness scale on a maximum 450 patient sample (current N = 300) at daily rounds administered in all inpatients admitted to the Hematology/Oncology Service January 4, 2016-June 30, 2016. Preliminary data shows 25-30% of study sample scoring in for Advance Care Planning with a score of greater than or equal to 4 on novel tool (BMC Cancer Care Severity Of Illness Tool).
The benefits and burdens of cancer: A prospective, longitudinal cohort study of adolescents and young adults.
Authors: Straehla Joelle P. , Shutske Krysta , Yi-Frazier Joyce P. , Wharton Claire M , Baker Kevin Scott , Bona Kira O'Neil , Wolfe Joanne , Rosenberg Abby R.
Published: February 2017

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Background: Much of the literature describing psychosocial consequences of cancer among adolescents and young adults (AYAs) has reported negative outcomes; however, AYAs also have potential for protective, positive outcomes. We aimed to prospectively characterize AYA patient-reported benefit and burden-finding after cancer diagnosis and hypothesized that benefit finding would be a salient coping mechanism. Methods: Semi-structured, 1:1 interviews were conducted with AYA patients after cancer diagnosis at 3 time points over 2 years, to elicit their expectations, hopes, worries, personal strengths, and challenges. A priori coding themes were defined from validated scales: changed sense of self, relationships, philosophy of life, and physical well-being. Verbatim transcripts were coded using content analyses by 3 independent coders for instances of benefit or burden by construct. Raw counts, ratios, and confidence intervals were calculated and compared by patient and time point. Results: Seventeen patients (mean age 17.1 ± 2.7; 8 [47%] male) completed 44 interviews with > 100 hours of transcript-data. Most common diagnoses were sarcoma (n = 8), acute leukemia (n = 6), and lymphoma (n = 3). Twelve patients completed all 3 interviews; reasons for withdrawal included death in all but 2 cases. Mean (±SD) counts of patient-reported benefit were higher than burden at each time point (T1, T2, T3); the benefit: burden ratio was > 1 in 68% of interviews (Table). Of the themes, changed sense of self was the most common benefit identified (44% of all reported benefits [95% CI 37%, 52%]) whereas physical complaints was the most common burden (32% [95% CI 25%, 39%]). Longitudinal analysis of subthemes among patients completing 3 interviews (N = 12) indicated an increase in self-identified positive and negative impact of cancer on personal, social and existential perspectives. Conclusions: AYA patients with cancer identified more benefits than burdens related to their diagnoses at all times studied. There was a shift over time in the distribution of benefit and burden finding constructs which may highlight areas for potential intervention. [Table: see text]
Differences in perceptions of smoking and second-hand smoke (SHS) in palliative and nonpalliative patients with cancer.
Authors: Mohan Rahul , Alton Devon , Su Jie , Song Yuyao , Farzanfar Delaram , Krys Olivia , Yoannidis Tom , Milne Robin , Brown M Catherine , Hope Andrew J. , Howell Doris , Jones Jennifer M. , Selby Peter , Xu Wei , Goldstein David Paul , Giuliani Meredith Elana , Liu Geoffrey , Eng Lawson
Published: February 2017

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Background: With improvements in cancer therapies, palliative patients with cancer now enjoy improved and sometimes prolonged survival. Continued smoking after a cancer diagnosis negatively impacts treatment response/toxicities, survival and quality of life and is influenced by SHS exposure. Little is known about the perceptions of palliative patients with cancer in comparison to patients who are considered potentially curative, on smoking after a cancer diagnosis and of SHS exposure. We assessed such potential differences in perception. Methods: Patients with cancer across all sites were surveyed with respect to their smoking habits and perceptions on how smoking and SHS influences cancer-related QofL, fatigue and overall survival (OS). Review of patient charts confirmed which patients were considered palliative versus potentially curative. Multivariable logistic regression models assessed for associations between treatment intent and patient perceptions, adjusted for significant co-variables. Results: Among 985 patients with cancer, 22% were considered palliative; 23% of surveyed patients smoked at diagnosis; 10% continued smoking at follow-up. Most patients perceived that continued smoking and SHS exposure negatively impacted QofL (continued smoking: 83%, SHS: 82%), fatigue (83%, 79%) and OS (86%, 81%). Palliative patients were more likely to believe that SHS worsened their cancer-related fatigue (adjusted odds ratio (aOR) = 1.65, 95% CI [1.05-2.56], P = 0.03) and worsened OS (unadjusted OR = 1.92, [1.12-3.33], P= 0.02; aOR = 1.56 [0.98-2.50], P = 0.06). Yet palliative/non-palliative status was not found to be associated with perceived benefits of smoking cessation on QofL, fatigue, or OS (P > 0.10, all comparisons). Conclusions: When compared with non-palliative patients, palliative patients with cancer perceived a greater negative impact of SHS on fatigue and survival, but had similar views of continued smoking after a cancer diagnosis. We are encouraged that palliative status did not lead to patients having diluted perceptions on the negative impact of smoking on cancer outcomes. Health care providers should continue to focus on the positive impacts of smoking cessation and SHS in this setting.
Differences between women’s preferred and actual experience with ‘shared decision-making’: A mixed method study.
Authors: Ejem Deborah , Dionne-Odom J Nicholas , Willis Danny , Kaufman Peter , Urquhart Laura , Bakitas Marie
Published: February 2017

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Background: Women with metastatic breast cancer (MBC) face numerous treatment and ACP decisions along their illness trajectory. We aimed to explore the treatment and ACP decision-making processes and decision support needs of women with MBC. Methods: Convergent, parallel mixed methods study (9/08-7/09). Sample included women with MBC managed by 3 breast oncologists at the Norris Cotton Cancer Center, Lebanon, NH. Participants completed a semi-structured interview and standardized decision-making instruments (decision control preferences) at study enrollment (T1; n = 22) and when they faced a decision point or 3 months later (T2; n = 19), whichever came first. Results: Participants (n = 22) where all white, averaged 62 years and were mostly married (54%), retired (45%), had a ≥ bachelor’s degree (45%), and had incomes > $40,000 (50%). On the control preferences scale, most women reported a preference for a ‘shared decision’ with clinician (T1 = 14 (64%) vs T2 = 9 (47%)) compared to making the decision themselves (T1 = 6 (27%) vs T2 = 6 (32%)), or delegating the decision to their doctor (T1 = 2 (9%) vs T2 = 4 (21%)). In semi-structured interviews about their actual treatment decision-making experience, women described experiencing a passive or delegated rather than a shared decision-making process. Conversely, women described a much more active ACP decision-making process that was often shared with family rather than their oncologists. Conclusions: Women selected a “shared” process using a validated tool; however their descriptions of the treatment decision-making processes were inconsistent with their actual experience, which was a more passive process in which they followed the oncologists’ treatment suggestions.