bluuebunny/crossref_metadata_2025 huggingface dataset:
The prevalence of cough in lung cancer: Its characteristics and predictors.
Authors: Harle Amelie Sylvia Mary , Buffin Oliver , Burnham Jack , Molassiotis Alex , Blackhall Fiona Helen , Smith Jaclyn A
Published: February 2017

162

Background: Cough commonly affects patients with LC but quoted prevalence figures vary and most were obtained before advances in anticancer treatment for LC. This study aimed to determine its prevalence and characteristics (severity, impact and potential predictors) in patients undergoing standard treatment and follow up. Methods: Consecutive LC patients attending clinics at The Christie Hospital, UK during a predefined 5 week period were asked whether they had a cough and invited to participate in its further evaluation according to an ethically approved protocol. Demographic, cancer and cancer treatment data were collected in all. Patients with a cough also completed subjective assessments using the validated cough impact Manchester cough in LC scale (MCLCS) and cough severity visual analogue scale (VAS). Standard statistical tests were used for analysis with significance (p<0.05). Results: Of 223 consecutive LC outpatients approached, the prevalence of cough was 57% (128/223); 202/223 (86%) consented to further data collection (study population) and of these 115 (57%) reported cough. The majority (60/115, 52%) felt that their cough warranted treatment and 23% reported their cough to be painful (26/115). The median VAS score (n=115) was 32mm (25th-75th IQR 20-51, range 0-100, high scores = worse cough severity). The median MCLCS score (n=113) was 22 (25th-75th IQR 16-27, range 1-50, high scores = worse cough impact). There was no significant difference between coughers and non-coughers with respect to age, sex, co-morbidities, smoking, performance status, treatment intent, treatment type, reasons for not receiving treatment, stage and histology. The proportion of non-coughers was lower among patients receiving anticancer therapy (45/115 39% vs 47/87 54%, p=0.04) in univariate analysis. Conclusions: Cough is present in the majority of LC patients, even in those undergoing treatment. Many patients feel that it warrants treatment. Whilst many consider factors such smoking, stage, histology and cancer treatment type to be important determinants of the presence of cough, our data does not reflect this. Improving LC related cough requires more than better cancer therapies.
Developing pathways for cancer rehabilitation in tertiary oncology centers: Initial observations at the McGill University Health Centre.
Authors: Cesare Sabrina , Uscatescu Irina , di Tomasso Jonathan , Ciutto Lorella , Yu-Chueh Kevin , Olders Henry , Aubin Nathalie , Kelly Mary Lou , Jelowicki Marta , Laroui Rabiaa , O'Grady Rosemary , Borod Manuel , Kilgour Robert , Vigano Antonio Angelo Luciano
Published: February 2017

17

Background: No definitive rehabilitation pathways exist for cancer patients. To address this gap, the Cancer Rehabilitation interdisciplinary team at the McGill University Health Centre has developed three program paths (e.g., Restorative, Supportive, and Cachexia) to meet the various specialized and personalized needs of cancer patients. Methods: A consecutive cohort of patients referred to the Cancer Rehabilitation Clinic between January 1st and June 30th, 2014 was considered. We examined the following baseline characteristics: handgrip strength (HGS), the abridged Patient Generated-Subjective Global Assessment (aPG-SGA) and Edmonton Symptom Assessment System (ESAS) self-reported questionnaires. Results: Of the 54 patients evaluated (57.4% male), 20 (mean age: 47.4 yrs), 8 (59.9 yrs) and 26 (64.6 yrs) were assigned to the restorative, supportive and cachexia streams, respectively. The most common cancer diagnoses were gastrointestinal (15%), gynecological (13%), breast (12%) and lung (12%). Table 1 contains baseline aPG-SGA, ESAS and HGS scores. Conclusions: Our preliminary data confirm clinically significant differences in muscle strength across the 3 streams for both males and females, as well as significant differences in nutritional, appetite and well-being scores between the patients in the restorative and cachexia pathways. Our data confirm the need of personalized and targeted interventions to achieve or maintain optimal performance and quality of life in cancer survivors with different disease and treatment characteristics. [Table: see text]
Fentanyl sublingual spray for breakthrough cancer pain in patients receiving transdermal fentanyl.
Authors: Alberts David S. , Rauck Richard L. , Parikh Neha , Forman Nicole
Published: February 2017

175

Background: Sublingual fentanyl spray is indicated for the treatment of breakthrough cancer pain (BTCP) in opioid-tolerant patients receiving around-the-clock (ATC) opioids. This post hoc analysis characterized patients receiving ATC transdermal fentanyl patch (TFP) who also received fentanyl sublingual spray for BTCP during a phase 3, randomized, placebo-controlled trial. Methods: Opioid-tolerant adults (n=130) receiving ATC opioids for baseline pain, with 1 to 4 episodes/day of BTCP, were enrolled in a 26-day open-label titration period and received fentanyl sublingual spray. Patients who successfully titrated to a stable, effective dose (100-1,600 mcg) of fentanyl sublingual spray entered a 26-day double-blind period. Patient satisfaction was assessed using the Treatment Satisfaction Questionnaire for Medication (TSQM). Adverse events (AEs) were monitored throughout the study. Results: Of the 50 patients (mean age, 50 years) who were on ATC TFP at baseline, most were male (58%) and white (90%) with a mean of 2.4 BTCP episodes/day. The most common types of cancer were reproductive (22%), head and neck (14%), and lung (8%). The percentage of patients in each cancer stage was 0/I (14%), II (10%), III/IV (48%), or unknown/not applicable (28%). Thirty-two of 50 patients (64%) achieved an effective dose of sublingual fentanyl spray and entered the double-blind period. In the 32 patients, the mean baseline TFP dose at the beginning of double-blind period was 81.4 mcg. The mean daily number of BTCP episodes during the 26-day double-blind period was 2.3 (range, 1-5). Mean TSQM scores at baseline and end of the titration period, respectively, were as follows: effectiveness, 49.0 vs 78.3; side effects, 65.0 vs 94.4; convenience, 61.6 vs 73.8; and global satisfaction, 49.3 vs 72.8. The effective dose of fentanyl sublingual spray only moderately correlated with the mean TFP dose (r=0.4; P=0.03). During the double-blind period, 19 of 32 patients (59%) reported AEs; the most common AEs were nausea (9%) and peripheral edema (9%). No opioid overdoses were reported. Conclusions: The findings support that fentanyl sublingual spray relieves BTCP and is well tolerated in most patients receiving ATC transdermal fentanyl. Clinical trial information: NCT00538850.
Supportive cancer care in-patient unit: A 3-year experience.
Authors: Scotte Florian , Legeay Karine , Maupoint de Vandeul Thyphaine , Leroy Pauline , Aubaret Christophe , Hans Stephane
Published: February 2017

185

Background: An in-patient unit for supportive care in oncology (USSO) was created in 2011 in the Georges Pompidou European Hospital. Its primary objective is to improve patient care and manage the complications of cancer as well as their specific treatment. Patients are previously screened by a cross disciplinary team at an early stage before complication. Methods: A prospective observational study was performed through a yearly evaluation of the unit’s activity from January 1st, 2011 to December 31st, 2013. Results: 594 patients were admitted in the unit during the three years period of study. Most of them (64.3%) came directly from home, with an increase of this rate along this period (59.4% to 67.6%). The early screening thereby rendered emergency admission from 17.7% (2011) to 6.5% (2013). The predominant diseases observed were head and neck cancer (42.4%) and lung cancer (23%), followed by breast (7.2%) and ovarian cancer (7.2%). The main grounds for hospitalization were state of health impairment 32%, pain 12.8%, and invasive procedures 11.8%, increasing from 2011 to 2013. Therefore, an interdisciplinary approach is the cornerstone of the unit with the daily collaboration of dieticians (for 90% of inpatients), social workers, psychologists, physiotherapists and pain specialists (34%, 46%, 56% and 50% of inpatients respectively). The average length of stay decreased from 2011 (10.2 days) to 2013 (8.3 days) and 58.4% of the patients were home discharged. With the help of a social worker, 12% of the patients were transferred to a recovery unit and 9.7% to a palliative care unit while 9% died in the unit. Conclusions: With the opening of the in-patient USSO, and the development of its interdisciplinary strategy, most of the patients recover faster and regain better health. Preventive care can accommodate a majority of patients coming from home and allows for ambulatory secured discharge. These positive results conducted to enhance the USSO’s beds capacity and supportive care development in order to improve cancer care organisation in the hospital as well as patient’s quality of life.
The McGill University Health Centre interdisciplinary approach to cancer pain management: Description of treatments and outcomes.
Authors: Olivier Sara , Perez Jordi , Shir Yoram , Borod Manuel , O'Grady Rosemary
Published: February 2017

190

Background: Cancer-related symptom management is best achieved by interdisciplinary teams. In 2011, the MUHC launched an interdisciplinary Cancer Pain Clinic including palliative care, anesthesia, radiation oncology and nursing with rapid access to physiotherapy, occupational therapy and psychosocial oncology. Methods: We retrospectively analysed all new outpatients completing two subsequent visits since March 2013. Variables included a) symptom severity with the Edmonton Symptom Assessment Scale (ESAS), b) pain with the Brief Pain Inventory (BPI) and c) treatment including medication (type, formulation, dose of opioids) of non-pharmacological approaches. Results: 71 patients were analysed. Symptom management: Severity of pain and other five symptoms decreased significantly at V2 or V3 (Table). Pain significantly decreased in all four BPI categories. One third of patients had ≥50% pain relief at V2 or V3. Number of severe pain cases decreased (45% at V1 to 18% at V3) in parallel to an increase of mild pain cases (11% at V1, 41% at V3). Treatments: Acetaminophen, anticonvulsants and NSAIDs were the most common non-opioid drugs. Opioid prescription remained constant at an 80% yet the ratio between short acting (SA) and long acting (LA) changed at V3 compared to V1 (V1: SA/LA=76/44; V3: SA/LA=48/58) and the morphine equivalent daily doses decreased (V1: 100±194 mg, V2: 84±158mg and V3: 65±80mg). Among non-pharmacological methods, 28% of patients received interventional procedures, 18% psychotherapy and 12% palliative radiotherapy. Conclusions: We believe that the pain and other symptom improvement observed after three visits along with a lower opioid consumption is a result of the interdisciplinary approach offered. [Table: see text]
Efficacy and tolerability of oxycodone for oxaliplatin-induced peripheral neuropathy and the extension of folfox therapy in colorectal cancer patients.
Authors: Nagashima Makoto , Ooshiro Mitsuru , Moriyama Ayako , Kadoya Kengo , Sato Ayami , Kitahara Tomoaki , Takagi Ryuichi , Urita Tasuku , Yoshida Yutaka , Tanaka Hiroshi , Oshiro Takashi , Okazumi Shinichi , Katoh Ryoji
Published: February 2017

196

Background: The oxaliplatin-based regimen FOLFOX is widely used to treat patients with advanced colorectal cancer (CRC). However, dose-limiting toxicity after continuous oxaliplatin administration can lead to peripheral neuropathy. Several agents, including opioids, that have been employed to treat oxaliplatin-induced peripheral neuropathy (OIPN) have been examined in clinical settings regarding their protective and therapeutic effects. However, the pharmacotherapy of these agents has not yet been established. Therefore, we investigated the efficacy and tolerability of oxycodone for OIPN and subsequently with FOLFOX therapy in CRC patients. Methods: This was a single-center retrospective study of 64 CRC patients who underwent FOLFOX therapy at the Toho University Sakura Medical Center (Sakura, Japan). Controlled-release (CR) oxycodone was concomitantly administered to 29 patients (OXY group), whereas the additional 35 patients (non-OXY group) were not given oxycodone during the FOLFOX treatment course. The incidence and severity of OIPN and the number of FOLFOX cycles were measured and compared between the two groups. Neurological toxicities were assessed according to the Common Terminology Criteria for Advanced Events, version 3.0. Results: All study patients had OIPN. Most patients experienced grade 1 or 2 sensory neuropathy. Grade 3 sensory neuropathy was observed in two patients in the non-OXY group. All patients in the OXY group completed the scheduled FOLFOX therapy, whereas FOLFOX therapy was discontinued in ten patients in the non-OXY group due to severe peripheral neuropathy. The median numbers of FOLFOX cycles in the OXY and non-OXY groups were 13 (range, 6–46) and 7 (range, 2–18), respectively (P < 0.05). The median cumulative oxaliplatin doses were 1072.3 mg/m2 (range, 408.7–3385.3 mg/m2) in the OXY group and 483.0 mg/m2 (range 76.2–1414.1 mg/m2) in the non-OXY group (P < 0.05). Conclusions: Our findings indicate that CR oxycodone might attenuate the severity of OIPN and extend the use of FOLFOX therapy.
Is opioid-induced hyperalgesia a genuine issue for palliative care patients and clinicans?
Authors: Eastman Peter , Le Brian H. , Grant Ian , Berry Sue
Published: February 2017

197

Background: Opioid-Induced Hyperalgesia (OIH) has been described as a paradoxical response whereby opioid administration induces an increase in pain sensitivity rather than an analgesic effect. It is proposed this results from increased pro-nociceptive sensitivity following changes in central and peripheral neural pathways. While there is basic science and pre-clinical evidence supporting OIH, debate remains about its clinical relevance or even existence. The existence or otherwise of OIH has relevance for palliative care as many patients are prescribed opioids and the standard management of unstable pain in palliative care may worsen symptoms in OIH. Therefore recognition of the concept would seem important for palliative care clinicians. Methods: An electronic survey of Australian and New Zealand palliative care clinicians was undertaken addressing awareness of OIH as well as approaches to recognising and managing it. The survey which contained single response, multiple-choice and open-ended questions was distributed through the Australian New Zealand Society of Palliative Medicine. Mixed-methods analysis was performed. Results: One hundred and twenty-three surveys were returned (response rate = 31%). The majority of respondents identified as palliative care specialists. More than 75% of respondents reported observing OIH in their clinical practice, often with malignant disease and with morphine, oxycodone and fentanyl identified as the commonest causal agents. The three features felt to be most suggestive of OIH were; escalating pain despite increasing opioids, demonstrable hyperalgesia or allodynia and a more diffuse pain distribution away from pre-existing pain sites. Most clinicians utilized more than one approach when OIH was encountered. The commonest of these were opioid reduction, opioid rotation and optimization of adjuvant analgesia. Conclusions: Our survey found a higher rate of reported observation of OIH amongst clinicians than might have been anticipated given debate about the existence of OIH in humans outside of a research environment. These results suggest that many palliative care clinicians perceive OIH to be a genuine issue for their patients.
Use of early radiation therapy in the palliative local treatment of stage IV esophageal cancer.
Authors: Hertan Lauren Michelle , Plastaras John Peter , Ben-Josef Edgar , Metz James M. , Jones Joshua Adam , Apisarnthanarax Smith
Published: February 2017

198

Background: Palliating local symptoms in stage IV esophageal cancer remains a challenge with no clear optimal initial intervention. Therapeutic options include radiation therapy (RT), chemotherapy (chemo), stent, or a combination of these treatments. We hypothesized that early initial RT would result in the best palliation of local symptoms in stage IV esophageal cancer patients. Methods: The study cohort included 72 patients with locally symptomatic stage IV esophageal cancer treated at the University of Pennsylvania from 2006-2012 and was split into those who received RT as part of their initial treatment (n = 42) versus those who did not (n=30; chemo alone, n = 18; chemo and stent, n = 9; stent alone, n=3). Demographics, baseline disease characteristics, treatment details, and clinical outcomes were analyzed. Results: Patient demographics and baseline characteristics were well balanced between the groups, except the RT group was less likely to have liver metastases (p=0.001). The RT group included both concurrent chemoRT (n=31) and RT alone (n=11, with or without sequential chemo). Median RT dose was 50.4 Gy (range 21 – 70 Gy). Chemotherapy regimens included 5-FU based or Carboplatin/Paclitaxel. Presenting symptoms included dysphagia (n=69, median grade 2), odynophagia (n=3, median grade 1), bleeding (n=5, median grade 3), and chest pain (n=3, median grade 2). No difference was noted in symptom improvement (median grade improvement = 1; p=0.25) or ECOG status (median improvement = 0; p=0.24) between the groups. However, patients who received upfront RT were less likely to have local symptom progression (% not having symptom progression: 69.1% [RT] v 43.3% [no RT]; p=0.003) and less likely to need repeat local intervention (% not requiring repeat local intervention: 81.0% [RT] v 33.3% [no RT]; p<0.0001). There was no difference in median time to first progression (11 mo [RT] v 11 mo [no RT]) or median survival (9.8 mo [RT] v 10.7 mo [no RT]). Conclusions: Early use of RT in locally symptomatic stage IV esophageal cancer patients results in effective palliation of local symptoms that may be more sustained compared to chemo alone or stent placement.
The practice of early palliative care: A qualitative study of patient-clinician encounters.
Authors: Lim Christopher Taekyu , Tadmor Avia , Fujisawa Daisuke , MacDonald James John , Gallagher Emily R. , Temel Jennifer S. , Greer Joseph A. , Park Elyse R.
Published: February 2017

2

Background: Studies have shown that palliative care (PC) integrated early in the course of metastatic cancer, shortly after diagnosis, leads to improved patient outcomes. Unlike PC in the inpatient setting, PC initiated early, in the ambulatory setting, had not been well studied. Our aim was to elucidate the practice of early PC through analysis of PC clinic visit transcripts. Methods: As part of an ongoing study of early PC in patients with advanced lung and gastrointestinal cancers at the Massachusetts General Hospital, we are audio-recording patients’ outpatient PC clinic visits. To capture the range of PC content, we randomly selected five patients and analyzed three clinic transcripts per patient: early, midway, and late in each patient’s clinical course. We performed thematic analysis on these clinic transcripts using NVivo 10. Results: Our analysis suggests that the elements of early PC that occur most frequently across the disease course are managing symptoms, facilitating coping, and developing the relationship with patients and their family caregivers. Elements that tend to occur during clinical transitions include advising treatment decision-making, facilitating medical understanding, and advance care planning. Our analysis also identifies four broad approaches to PC that are applied longitudinally, over the course of the patient-clinician relationship: 1) eliciting versus commenting on patients’ perspectives, 2) alluding to and preparing for the future, 3) transitioning between managing symptoms and facilitating coping, and 4) transitioning between developing the relationship and facilitating coping. Lastly, we observe three specific techniques applied by PC clinicians: 1) coordinating with oncologists, 2) providing referrals, and 3) addressing family dynamics. Conclusions: Our study identifies the predominant elements, four longitudinal approaches, and three specific techniques of early PC. These novel insights can be applied to care delivered by both PC and non-PC clinicians, well before patients approach the end of life. The longitudinal approaches in particular may help explain the significance of early integration of PC into cancer care.
Supportive care organization: Patients and oncologist national survey comparison.
Authors: Scotte Florian , Herve Christian , Tourani Jean Marc , Bugat Roland , Farsi Fadila , Jovenin Nicolas , Namer Moise , Tournigand Christophe , Leroy Pauline , Oudard Stephane , Krakowski Ivan
Published: February 2017

202

Background: The medical doctor's (MD) perspective of supportive care in cancer (SCC) in France was previously assessed on a national survey. However, the opinion of patients (P) has never been evaluated nor compared to MD’s perception.Wepromoted and compared P and MD awareness via national surveys to monitor implementation and information delivered to patients on SCC. Methods: The French Speaking Association for SCC (AFSOS) conducted two observational studies, analyzed with a Chi2 test: S1: a 30 points questionnaire sent to 2,263 physicians caring for cancer P (oncologists, radiotherapists, haematologists, gastroenterologists); and S2: a 40 points questionnaire performed by physicians to P, using a face-to-face method. Results: 711 MDs returned S1 and S2 was conducted with 1,562 P. In S1, MDs declared relying on SCC organization (81%) but 19% of P declared they were offered to benefit from an organization called SCC (54% at diagnosis, 35% after complication). The name SCC was known by 34% of P, most frequently described as complementary care to specific treatments (55%). Palliative Care word had been previously heard by 80% P, mostly considered as care to improve quality of life during cancer treatment for 59%. In S2, professional resources identified outside the hospital were: general practitioners (84%), nurses (58%), pharmacists (52%). According to P, the top 3 supportive care consultations proposed were psychology (61%), nutrition (55%) and announcement organization (55%), while MDs mentioned palliative care (98%), psychological care (98%), social care (98%), S2 showed that supportive treatment was prescribed to 63% of P, mostly by their oncologist (74%), and 64% of those P received information on side-effects. Epoetin was prescribed to 25% and analgesics to 73%, with discussion on adverse events respectively for 38% and 53%. MDs declared delivering information on adverse events to 49% of P receiving epoetin and to 74% of P running for analgesic treatment. Conclusions: Oncologist is the cornerstone of SCC organization. Information as well as treatment must be developed to further enhance SCC and patient quality of care.
Long- and short-acting opioids in cancer pain management: What is the best ratio?
Authors: Wiesenthal Alison , Moryl Natalie , Glare Paul A.
Published: February 2017

206

Background: Many cancer patients experience chronic and breakthrough pain necessitating the use of both immediate release (IR) and extended release (ER) opioids. The common strategy in treating chronic cancer pain is using ER opioids with the addition of IR opioids for breakthrough pain. The National Comprehensive Cancer Network recommends IR dosing at 0.1-0.2 times the daily ER dose as needed every 1 hour for breakthrough pain, though data is lacking to validate this recommendation. The aim of this exploratory study was to review the current practice in prescribing IR and ER opioids and the IR/ER ratio used in cancer pain management at one comprehensive cancer center (CCC). Methods: We performed a retrospective chart review of 54 consecutive patients at a CCC over a 6 month period. IR/ER doses, dose adjustments and satisfaction with analgesia were recorded. Adjustments in treatment plans were made based on patients' report of effectiveness and side effects associated with ER and IR opioids. Results: 19 of 54 (35%) patients reported adequate analgesia, with the average daily prescribed IR/ER ratio of 0.6 (range 0 to 3.75). In this group, IR opioids were unchanged during the clinic visit. The ER opioids, on average, were also unchanged, though decreased by 25% and increased by 50% in a few cases over serial clinic visits. Of those patients reporting suboptimal analgesia during the clinic visit (65%), 80% had their ER opioids increased, 6% had IR opioids increased, and 9% had both IR and ER increased. The ER opioids were increased by 40% on average and IR by 11% with the average IR/ER ratio changing from 0.5 (range 0-2) to 0.37 (range 0-1.13). Conclusions: These preliminary data highlight the great variability between patient preferences and clinician decisions in terms of IR/ER opioid ratios. In this retrospective study, analgesia was better in the group using higher IR doses with a higher IR/ER ratio. At the same time, patients with suboptimal analgesia had their ER opioids titrated faster and higher than the IR opioids. More studies are needed to determine best practice in the prescribing of long and short acting opioids for management of chronic cancer pain.
Usage of biosimilar filgrastim: A subanalysis of the next study.
Authors: Maloisel Frederic , Leprêtre Stephane , Kamioner Didier , Berthou Christian , Albrand Helene
Published: February 2017

216

Background: Febrile neutropenia (FN), a major risk factor for morbidity/mortality, is associated with dose delays and/or reductions in potentially cytotoxic chemotherapy (CT) regimens. European recommend prophylactic use of granulocyte-colony stimulating factor (G-CSF) when using a CT regimen associated with a >20% risk of FN or in less intensive CT regimens if certain risk factors (eg >65 years, advanced disease) are present. Biosimilar filgrastim (Nivestim, Hospira Inc.) is a G-CSF licensed for the treatment of neutropenia and FN induced by myelosuppressive CT. As the NEXT (Nivestim safety profile in patients [pts] treated with cytotoxic CT in real-life clinical practice) study was conducted in France, the real-life usage of biosimilar filgrastim is compared with that recommended by current European guidelines. Methods: NEXT was a prospective, non-interventional, longitudinal, multicentre study conducted in France. Pts were undergoing CT for malignancies and receiving biosimilar filgrastim as prophylaxis or as curative treatment. This subanalysis included only pts receiving prophylactic biosimilar filgrastim. Individual FN risk factors were analysed. Results: Overall, 2102 pts were analysed in the study and 2065 pts received prophylactic biosimilar filgrastim. Of these, 19.4% received CT associated with a high risk of developing FN (intermediate risk 55.6%; low risk 25.0%). Of the pts receiving CT regimens associated with an intermediate or low risk of FN, 95.4% and 96.5%, respectively, had ≥1 risk factor for FN (Table). Of all pts analysed, 2.4% developed FN, 11.2% developed an infection and 2.4% were hospitalised for FN and/or infection after the first CT cycle. Median delay between the last CT dose and start of treatment was 2 days; mean ± SD duration of treatment was 6.0 ± 3.8 days. Conclusions: The majority of pts received prophylactic biosimilar filgrastim according to European guidelines (ie either had >20% risk of FN or had ≥1 FN risk factor). Clinical trial information: NCT01574235. [Table: see text]
Acute myeloid leukemia (AML) patients' understanding of prognosis and treatment goals: A mixed-methods study.
Authors: LeBlanc Thomas William , Bloom Catherine T , Davis Debra M. , Locke Susan C. , Steinhauser Karen E. , Ubel Peter A. , Tulsky James A. , Abernethy Amy Pickar
Published: February 2017

221

Background: Patients with AML face complex information about the risks and rewards of pursuing treatments of varying intensity. Little is known about what patients understand or value in the decision-making process. Methods: AML inpatients receiving induction chemotherapy completed weekly electronic surveys about their prognosis and treatment goals, along with a baseline semi-structured, qualitative interview exploring their understanding of illness. Their oncologists (MDs) completed baseline surveys about prognosis and treatment goals. We followed a mixed-methods approach to analysis, applying standard statistical methods to survey data, and a constant-comparative qualitative approach to the interview data to enrich our understanding of survey results. Results: We enrolled 13 dyads (a patient and MD pair). Mean patient age was 65.5, and all had high-risk disease due to either age >60, complex cytogenetics, secondary AML, or relapsed disease. At baseline, mean MD-rated chance of cure was 27% (SD 17.6), while patients’ rating was 54% (SD 34.7; p=0.02). Only 2 patients’ estimates of cure matched their MD’s rating, yet MDs rated their patients’ prognostic understanding as high (mean 7.2 on an 11-point scale). MDs reported an average of 3.1 available treatment options, but patients recalled just 1.5. Most MDs gave a specific treatment recommendation (11 of 13), and most patients received the recommended treatment (10 of 11). Agreement about treatment goal was markedly worse than expected by chance (kappa -0.41; 95% CI -0.88-0.07). Qualitative analysis suggests that patients often viewed treatment decisions as binary “life-or-death” propositions, rather than choices between options with differing goals and intensities. Patients also significantly underestimated the risks of induction chemotherapy. Conclusions: AML patients receiving induction chemotherapy have a poor understanding of their prognosis, treatment goals, and risks of induction chemotherapy, but their oncologists are not aware of this. These findings suggest the need for an intervention to improve patient understanding of their illness and treatment options.
Assessing the Preparatory Grief in Advanced Cancer Patients (PGAC) instrument in an American population.
Authors: Vergo Maxwell Thomas , Whyman Jeremy D. , Kestel Jeanne , Rector Christopher
Published: February 2017

225

Background: Only 50% of cancer patients who screen positive on the Distress Thermometer accept referral to psychosocial resources and mainly for challenges coping with overwhelming emotional response to losses. The Preparatory Grief in Advanced Cancer (PGAC) instrument was shown to have significant associations with hopelessness, anxiety, and depression in a Greek population with favorable potential as a screening tool. We aimed to assess the use of the PGAC in a sample of American patients diagnosed with incurable cancer as a more efficient screening tool for patients who would benefit from additional psychosocial referrals. Methods: We conducted this survey with participants from Northwestern University in Chicago, IL. Participants were US citizens and >18 years old with an incurable cancer and no history of substance abuse or current psychiatric diagnosis. Patients were asked to complete a single survey composed of demographic data and scales including the PGAC, Distress Thermometer, HADS, ESAS and QOL. We used pair-wise correlation measurements, which included p-value measurements for testing whether the correlation coefficient was significantly different from 0. We then used pair-wise correlation coefficients to assess for p-value < 0.05 at different PGAC scores. Results: 53 patients were surveyed, of which 57% (30) were outpatients. The PGAC score was associated with the distress thermometer (R=0.74, p=<0.001), HADS (R=0.65, p=<0.01), and ESAS (R=0.49, p=<0.01) as well as inversely correlated with QOL score (R=-0.45, p=<0.001). Additionally, PGAC > 21 (p=0.02) was associated with elevated distress thermometer score (p=0.02) and elevated HADS scores (p=0.04). Conclusions: We tested the PGAC in an American population for the first time and found correlation between PGAC other validated measures (Distress Thermometer, ESAS, HADS, QOL) in an American population. We propose a PGAC cutoff of >21 to assess for preparatory grief due to its association with elevated scores on Distress and HADS scales above this threshold. This instrument may better identify patients struggling with coping who would benefit from additional support but further investigation is needed.
Early introduction of palliative care for children with solid tumors.
Authors: Fernandez Karen S. , Lucia Rober J. , Buchheit Rachel , Holman Michele J. , Sandiford Penelope , Sollenberger Laura M.
Published: February 2017

23

Background: Patients with solid tumors (ST) have the highest rate of relapse and mortality among pediatric oncology. Many patients suffer from acute and chronic therapy-related toxicity that have major implications in the patients’ lives. An early introduction of palliative care consultation (PCC) for patients with ST was implemented in 2012. Objectives: To assess the impact of the early introduction of PCC for children with ST on 1) Facilitation of interdisciplinary meetings (IDM) and goals of care 2) Counseling support including coping, advocacy, self-care, 3) Grieving, 4) End-of-life decision making/planning, and 5) Bereavement. Methods: An audit of all PCC from November/2012 to May/2014 was performed. Newly diagnosed patients with high risk ST (metastatic disease, need for HSCT or risk for relapse of > 30%) were eligible for early PCC (36/44). Patients with brain tumors were excluded (19). Counselors were introduced to the patient/family at diagnosis. The perception of the intervention was explored among physicians and counselors. Results: 29/35 patients (72%) were offered early PCC, 1 declined the intervention. 17/29 developed disease relapse or progression (58%), 11/17 died. 9/29 had high risk ST without relapse (31%), 6/29 had loss of physical function (21%), 5/29 had other chronic diseases (17%). 20 had IDM for re-direction of goals of care. 25 (86%) received at least 1 of 3 counseling aspects. 20 received grieving support during treatment (6 due to loss of physical function, 4 during relapse and 11 during the dying process). 11 received end-of-life and bereavement support. Median number of visits/patient was 14. Pediatric oncologists felt early PCC favored effective communication between patients/families and medical teams, counselors felt early PCC was critical for rapport and trust building for an effective and productive professional relationship that strengthen the continuity of care. Conclusions: Early PCC for children with ST is feasible, and well-accepted by patients/families and physicians. It facilitates the comprehensive care of patients with ST throughout the disease trajectory.
Creating communicative opportunity: The supportive benefits of legacy building for families of advanced cancer patients.
Authors: Bernat Jennifer Kim , Helft Paul R. , Wilhelm Laura R. , Schmidt Karen , Johns Shelley A.
Published: February 2017

230

Background: Being diagnosed with advanced cancer is a painful reality that impacts entire families. Families face the challenge of great loss and can regret conversations left unspoken. Dignity therapy (DT) is an empirically supported intervention that gives families communicative opportunity. During DT, terminally ill patients engage in legacy building and create a written project containing their meaningful memories and values. This project is given to the family, succeeding the person in death and providing continuity to those who are left behind. We developed a narrative intervention based on DT that used a novel web portal for project dissemination. This study qualitatively explores the family’s reactions to legacy building to learn about its potential for future bereavement support. Methods: Semi-structured phone interviews (20-30 minutes) with family members (n=7) of terminally ill cancer patients were completed approximately one week after receiving the legacy project. Recipients were spouses (n=4), siblings (n=2), or an adult child (n=1). Interviews were coded using conventional content analysis and an open-coding strategy. Themes were recorded as they emerged. Results: Three communication themes emerged from the data. Legacy building: (1) facilitates conversation; (2) creates new knowledge and understanding; and (3) leaves lasting communication for future generations. The family members felt overall communication improved before the patient died, and they were able to discuss the terminal nature of their loved one’s illness. New knowledge was communicated in the project, which sometimes led to further understanding of personal life events. Also, the project was viewed as a family heirloom to be bequeathed to future generations. All family members stated they would recommend legacy building to others. Conclusions: This study adds the unique impact of communication to the literature on the supportive benefit of DT for families of advanced cancer patients. Future research should investigate and quantitatively assess bereavement outcomes for families over time, as well as the direct impact these outcomes have on family members’ quality of life.
Stress and empathy among internal medicine trainees on an inpatient hematology-oncology ward.
Authors: McFarland Daniel Curtis , Kirkwood Katherine , Maki Robert G.
Published: February 2017

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Background: Effectively managing patient distress in oncology is challenging. Just as patients and their families experience distress over cancer, trainees in oncology also experience distress. This study evaluates whether increased physician-in-training distress acutely reduces empathy. Terror Management Theory provides the theoretical framework for the hypothesis. Methods: 35 internal medicine interns and residents completed a pre and post rotation Impact of Events (IES) and Interpersonal Reactivity Index (IRI) for comparison after 2-4 weeks. IES and IRI measure distress and empathy respectively. Results: Overall IRI empathy decreased (paired t-test, p=0.02) but only significantly in the Fantasy subscale (p=0.008). Empathy scores were below historical controls and did not differ between males and females (p=0.06). Pre and post rotation IES scores averaged 19.7 and 20.7. Distress was significant (>8) in 82% and 88% and severe (>33-PTSD range) in 20% and 22% of Pre/Post IES, respectively. Time on the ward averaged 2.6 weeks and residents attended to 4.6 actively dying patients, of which 38% stated it was "the most stressful experience"; however, 56% found "meaning" in the work. 48% mentioned patient death as the traumatic event (responding to IES). Conclusions: Residents demonstrated pathological levels of distress which affected aspects of empathy in a short period of time and related predominately to death experiences. Ultimately, physician self-management of vicarious distress during oncology training and enhanced maintenance of empathy could improve patient distress management, but this idea will require further study. [Table: see text]
Linking dispositional mindfulness and positive psychological processes in cancer survivorship: A multivariate path analysis.
Authors: Beck Anna Catherine , Garland Eric , Thielking Paul , White Shelley
Published: February 2017

237

Background: Research indicates dispositional mindfulness is linked with positive psychological outcomes. This disposition, which is malleable through training, is characterized by the tendency exhibit nonjudgmental and nonreactive awareness of one’s thoughts, emotions, and present moment sensory-perceptual experience. Although this trait has been linked with salutary outcomes in the broader mental health literature, less is known about the trait of mindfulness in cancer survivors and how it may be linked with indices of psychological and physical health relevant to cancer survivorship. Methods: We conducted a multivariate path analysis of cross-sectional data from a heterogenous sample of cancer patients (N = 97) to test a conceptual model linking dispositional mindfulness with cancer-related quality of life via positive psychological processes. Results: We found that patients with higher levels of dispositional mindfulness were more likely to pay attention to positive experiences (β = 0.47), a propensity which was associated with positive reappraisal of stressful life events (β = 0.46). Patients who endorsed more frequent positive reappraisal had a greater sense of sense of meaning in life (β = 0.43) and savored rewarding or life affirming events (β = 0.45). In turn, those who engaged in high levels of savoring had better quality of life (β = 0.33) and suffered from less emotional distress (β = -0.54). Overall model fit was excellent, χ2/df= 1.18; CFI = 0.99; RMSEA = 0.04 (0.00, 0.12). Conclusions: The data support our hypothetical model of the processes by which mindfulness promotes psychological flourishing in the face of cancer. Dispositional mindfulness appears to broaden attention from a myopic focus on illness to encompass previously unattended positive features of the social and natural environment. With this broader set of information from which new, more adaptive situational appraisals may be generated, mindfulness may engender positive reappraisals of stressful life events and promote sense of meaning in life. When sustained over time, these processes may propel an upward spiral of positive cognition-emotion interactions with salutary consequences for cancer survivorship.
Psychosocial outcomes in active treatment through survivorship.
Authors: Reed Sarah C. , Bell Janice , Whitney Robin L. , Davis Andra , Lash Rebecca Salisbury , Kim Katherine , Copenhaver David , Bold Richard J. , Joseph Jill G.
Published: February 2017

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Background: An estimated 13.7 million cancer survivors live in the United States, a population projected to reach 18 million in 2022. Late- and long-term psychological and emotional effects of cancer can be severe and unfortunately, often go unrecognized and untreated. Few population based data exist that capture psychosocial outcomes across the cancer continuum, from active treatment through survivorship. Methods: We analyzed the Medical Expenditure Panel Survey (MEPS) Experiences with Cancer Survivorship Supplement (n=1,592) to examine psychosocial outcomes among active treatment and survivorship patients across the post-treatment trajectory. Survey-weighted regression models were used to determine the risk of depression (PHQ-2), psychological distress (K-6) and cancer-specific worry related to recurrence. The primary independent variable was post-treatment survivorship status, categorized in years (1-2; 3-4; 5-9; 10-20; >21years) compared to active treatment as the reference group. All models were adjusted for plausible confounding variables (age, sex, race/ethnicity, marital status, employment, income, education, health insurance and health status). Estimates are generalizable to US non-institutionalized populations. Results: No significant difference in the risk of depression (PHQ-2) or psychological distress (K-6) was evident between those in active treatment and cancer survivors at any time post-treatment and those in active treatment. In contrast, cancer-specific worry was significantly higher among those respondents in active treatment (OR 4.3; 95% CI: 2.8, 6.6) compared to those post-treatment. Within the post-treatment survivorship categories, cancer-specific worry generally declined with time post-treatment; however these associations were only significant among those whose treatment was more than 20 years ago (OR= 0.12; 95% CI: 0.04, 0.36) relative to those in active treatment. Conclusions: Psychosocial concerns are pervasive among cancer survivors and are similar to concerns among individuals undergoing active treatment. These findings highlight unmet psychosocial needs among cancer survivors and demonstrate the importance of targeted interventions across the survivorship continuum.
Oncologist liaison: Satisfaction and symptoms in cancer long survivors.
Authors: García Navalón Francisco Javier , Monfort García Rosa , Cunquero Tomás Alberto Jacobo , Umanzor Funez Gerardo Antonio , Palomar Coloma Virginia , Iranzo Vega , Blasco Ana , Camps Carlos
Published: February 2017

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Background: Each year, the prevalence of cancer long survivors (CLS) increases; defined as a person who after five years of diagnosis and treatment is free from disease. Health problems faced by these patients are different from those in general population. Because of that, our service launched in 2007 the figure of the Oncologist Liaison, which acts as a link, and is responsible for assessing these Patients at Specialty Centers. Methods: 238 questionnaires, answered by CLS, were collected between January 2013 and April 2014. Variables of interest were collected by a 18-item questionnaire, designed to assess the aftermath of treatment, socio-emotional impact and employment impact. To assess the performance, methods of descriptive statistics have been used. Results: 90.6% of CLS believe that Oncologist Liaison improves their quality of life, with a decrease in anxiety in 80% of them. 52% of the patients (124) have residual symptoms, being the most frequent asthenia (27.6%). The most prominent symptoms were neurological, such as insomnia (16.5%), anxiety (17.4%) and depression (12.2%). Musculoskeletal problems included myalgia (29.5%), arthralgia (27.5%) and paresthesias (18.3%). Cancer and its treatment have a great impact in sexuality, affecting the 35% of the patients: 24'6% have sexual appetite loss and 7.5% dyspareunia; 10.5% of the men refer impotence and premature ejaculation 5% of them; 28.5% of the women referred vaginal dryness. Conclusions: First, more than half of our patients presented residual symptoms; reporting 90% of them improvement in quality of life related to surveillance. Second, it is necessary to create in our Medical Oncology Services a professional dedicated to coordinate the scientific and organizational aspects necessary for a good follow-up of CLS.
Symptom distress and symptom clusters in underserved Chinese-American cancer patients.
Authors: Dhingra Lara , Lam Kin Y. , Cheung William , Shao Theresa H. , Li Zujun , Van de Maele Sandra , Chang Victor Tsu-Shih , Chen Jack , Ye Huiyan , Wong Rhoda , Lam Wan , Chan Selina , Bookbinder Marilyn , Dieckmann Nathan , Portenoy Russell
Published: February 2017

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Background: Cancer is prevalent in the rapidly-growing Chinese-American community, yet little is known about symptom burden to guide comprehensive treatment planning. We evaluated symptom distress and symptom clusters in a large sample of Chinese-American patients with cancer. Methods: Patients were consecutively recruited from four oncology practices and completed a translated cancer symptom scale. Latent class cluster analysis explored symptom distress clusters in patients. Results: Of 1,436 patients screened, 94.4% were non-English speaking and 45.1% were undergoing active cancer therapy. The most common cancer sites were breast (32.6%), lung (14.8%), head and neck (12.5%), and hematologic (10.1%). Overall, 1,289 (89.8%) patients had > 1 symptom and 1,129 (78.6%) patients had > 2. The most prevalent symptoms were lack of energy (57.0%), dry mouth (55.6%), feeling sad (49.3%), worrying (47.5%), and difficulty sleeping (46.8%). Symptoms causing “quite a bit” or “very much” distress included: difficulty sleeping (37.9%), lack of appetite (37.2%), feeling nervous (35.8%), pain (35.2%), and worrying (34.0%). Four symptom distress clusters were identified: very low physical and psychological symptom distress (49.5%); very low physical and moderate psychological symptom distress (25.2%); moderate physical and psychological symptom distress (17.4%), and high physical and psychological symptom distress (7.8%). Patients in the last group reported lack of energy, difficulty sleeping, pain, feeling sad, and worrying. Conclusions: Symptom prevalence is high in community-dwelling, Chinese-American cancer patients and half experience moderate to high distress from clusters of physical symptoms, psychological symptoms, or both. These data have important implications for the development of effective interventions for symptom control.