bluuebunny/crossref_metadata_2025 huggingface dataset:
Utilization of single-fraction radiotherapy for the treatment of bone metastases before and after the “Choosing Wisely” campaign.
Authors: Curry Heather A , Forastiere Arlene A. , Flood William A. , Whyler Elaine , Hertan Lauren Michelle , Sharma Sonam , Jones Joshua Adam
Published: February 2017

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Background: Multiple studies have demonstrated equivalence of single vs. multi-fraction regimens for palliation of uncomplicated bone metastases, but single fraction (SF) radiotherapy (RT) remains under-utilized in the United States. To increase physician and patient awareness of RT options for bone metastases, both AAHPM and ASTRO participated in the “Choosing Wisely” campaign. AAHPM recommended 8 Gy X 1 for uncomplicated bone metastases. ASTRO recommended against routine use of courses > 10 fractions and supported strong consideration for the use of SF RT for patients with limited prognosis or transportation difficulties. To identify possible changes in prescribing patterns following “Choosing Wisely”, we evaluated utilization rates of SF (8 Gy x 1) for treatment of bone metastases via treatment requests submitted for preauthorization over a 3 year period. Methods: A proprietary web-based application (eviti Connect ) enables oncology providers to obtain real time automated precertification for patients insured by payers across the U.S. that utilize the platform. All preauthorization requests for RT of bone metastases were evaluated for the prescription of 8 Gy X 1. The overall rate of SF use was calculated as were quarterly rates within the study period. Results: From 6/1/11-6/30/14 7,524 requests were submitted; 658 were for bone metastases. Overall SF was used in 7.6 % of cases. Prior to Q4 of 2012 no prescriptions for 8 Gy X 1 were used. In 2013 SF was prescribed in 9.6% of cases (30/314): 2.8%, 7.3%, 7% and 20% for Q1, Q2, Q3, and Q4 respectively. During 2014 use of 8 Gy X 1 was 23.9% in Q1 and 19.5% in Q2. Protracted schedules > 10 treatments were prescribed in 31% of cases, but decreased over the study period (from 40% prior to Q4 2012, to 28% in 2013, and to 23% in the first half of 2014). Conclusions: Within this unique dataset of working aged insured patients, utilization of 8 Gy X 1 for treatment of bone metastases has increased. Increases were most pronounced in 2013. This coincides with the announcement and dissemination of the “Choosing Wisely” initiatives. Longer follow-up is needed to determine if increased provider uptake of SF RT as a componant of patient-centered quality care persists.
Health care quality experiences among cancer survivors in the United States, 2011.
Authors: Bell Janice , Whitney Robin L. , Reed Sarah , Davis Andra , Kim Katherine , Copenhaver David , Bold Richard J. , Joseph Jill G.
Published: February 2017

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Background: Recent national reports highlight gaps in the quality of health care received by the growing population of cancer survivors in the United States. A deeper understanding of the health care experiences of cancer survivors and related disparities could inform interventions designed to address these gaps. Methods: Data from the 2011 Medical Expenditures Panel Survey Household Component and Experiences with Cancer Survivorship Supplement (n=1,592) were used to compare health care experiences of survivors those those of individuals in active treatment. Logistic regression models of three outcomes (receipt of necessary care; detailed discussions with providers about late or long-term side effects of cancer treatment; and detailed discussions with providers about lifestyle or health recommendations e.g., diet, exercise, quitting smoking) were controlled for potential confounding variables including age, sex, health insurance status, education, race/ethnicity, and marital status. Survey weights were applied to account for the complex sampling design and estimates are generalizable to the US civilian, non-institutionalized population. Results: Most respondents (96%), whether or not they were in active treatment, reported they had received all medical care, tests, or treatments that they or their providers believed were necessary. Fewer survivors, compared to respondents in active treatment, reported their providers had discussed late or long-term side effects (37% versus 61%; p<0.01) or lifestyle recommendations with them in detail (57% versus 72%). These associations persisted in the multivariable models of side effect discussions (OR=0.38; 95% CI: 0.26, 0.55) and lifestyle recommendations (OR=; 95% CI: 0.35, 0.68) regardless of the length of time since treatment had finished. Subgroups with lower odds of all three outcomes included those with public or no insurance and those with lower levels of education. Conclusions: Care received after treatment for cancer may not fully address the unique needs of cancer survivors and, in particular, those with public or no insurance and with low levels of education regardless of treatment status. Targeted interventions with a focus on these subgroups may be required.
Skeletal-related events (SREs) and survival among elderly patients with stage IV prostate cancer (PCa) in SEER Medicare data.
Authors: Onukwugha Ebere , Kwok Young , Yong Candice , Franey Christine , Mullins C. Daniel , Seal Brian S. , Valderrama Adriana , Hussain Arif
Published: February 2017

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Background: Skeletal-related events occurring among PCa patients with bone metastasis include radiation to the bone (RttB), pathological fracture, spinal cord compression (SCC), and bone surgery (BS). There is no validated algorithm for identifying RttB using claims data. We investigated the prevalence and mortality impact of SREs across alternative claims-based algorithms for identifying RttB. Methods: We analyzed data for stage IV PCa cases identified between 2005 and 2009 in the Surveillance, Epidemiology, and End Results registry linked with Medicare claims. Fracture, SCC, and BS were identified from claims. Focusing on external beam radiation therapy, radiopharmaceutical therapy, intensity modulated radiotherapy and stereotactic radiosurgery, three approaches were created based on data visualization software: 1) radiation claim occurred after a claim with a bone metastasis (BM) code; 2) BM code directly coincided with the period of the radiation treatment episode; 3) either #2 or the duration of the radiation episode was less than or equal to 4 weeks. Regression models for all-cause mortality used these measures. Results: The study sample included 5,380 men with stage IV PCa. The median age of the sample was 77 years. All-cause mortality was 54% during median (mean) follow-up of 579 (656) days. The proportion who had any fracture, SCC, and BS was 23.2%, 6.3%, and 5.8%. Without taking BM code or duration of radiation into consideration, the proportion who received radiation therapy was 35%. Using approaches 1, 2 and 3 we have the following four results: 1) the proportion who received RttB was 22%, 18%, and 24%; 2) the prevalence of any SRE was 39%, 37%, and 41%; 3) among those with an SRE, the proportion receiving RttB was 57%, 50%, and 58%; 4) the adjusted hazard ratio (95% CI) associated with any SRE was 1.22 (1.13–1.33), 1.22 (1.12–1.33), and 1.25 (1.15–1.36). Conclusions: Among older men diagnosed with stage IV prostate cancer, approximately one in five men received palliative radiation and the mortality impact of skeletal-related events was comparable across alternative approaches to identifying palliative radiation.
The importance of communication about cachexia as experienced by patients and caregivers: A qualitative cross-cultural study.
Authors: Del Fabbro Egidio , Borneman Tami R. , Graffigna Guendalina , Cecchini Isabella
Published: February 2017

37

Background: Cancer Anorexia-Cachexia Syndrome (CACS) is a multifactorial condition defined by an ongoing loss in body weight that cannot be fully reversed through conventional nutritional support and leads to progressive functional impairment. This condition has for a long time been misrecognized and underdiagnosed. Furthermore, the burden of CACS as experienced and depicted by patients and caregivers has not been deeply explored so far. Methods: This was a narrative qualitative cross-cultural study (IT, ES, UK, DE, US) based on the collection of 30 weekly emotional diaries followed by 30 semi-structured in-depth interviews to caregivers (i.e. relatives, partners, close friends) of patients diagnosed with CACS. The aim was to understand how the disease is experienced by patients and caregivers, their feelings and unmet needs. Results: Caregivers and patients demonstrate a poor knowledge of CACS: while they spontaneously refer to a pattern of CACS symptoms, they do not verbalize the term “cachexia”. The awareness and levels of engagement in managing CACS by caregivers appear to be dependent on the degree and timing of communication on this condition with the physician: those who express a higher sense of powerlessness and despair also report that their doctor has never explicitly mentioned CACS, nor indicated any strategies to manage it. On the other hand, those who appear more confident and engaged in managing CACS report a more detailed and earlier communication on the subject. Conclusions: Scarce and/or late communication on CACS and its management options with patients and caregivers may result in a sense of powerlessness and ignorance on how to manage its symptoms. In line with the recently reported importance of an early CACS recognition [(Aapro M et al, Ann Oncol (2014). 2014 May 2)], an earlier and thorough discussion about CACS with patients and caregivers would improve their level of engagement and help relieve some of their distress.
Feasibility of outpatient palliative care for oncology patients within the safety net.
Authors: Harris Heather A. , Kinderman Anne , Kerr Kathleen
Published: February 2017

38

Background: Palliative care (PC) combined with standard oncology care has been shown to improve patient outcomes and reduce health care costs. In safety-net systems, where limited resources mandate containing costs across settings, outpatient PC (OP PC) could be an important tool for improving quality while lowering costs. Multiple studies have shown that oncology patients cared for in safety net systems often present very late in the course of illness, raising concerns about the proportion of patients who could be referred to an OP PC clinic. To address this question we analyzed utilization patterns among cancer patients cared for at our facility to examine the need for and expected net costs of an OP PC service. Methods: Retrospective cohort study of oncology patients cared for at an urban, safety-net hospital who died between July 2010 and June 2013. We used cancer registry data to identify decedents and claims data to evaluate utilization patterns and cost of care in the final 6 months of life. Results: Among the 403 cancer patients who died in the study period we found heavy, late utilization of inpatient (IP) services: 307 (76%) were admitted to the hospital in the 6 months preceding death, 45% in the final month of life. One third of patients died in the hospital and another 4% died within 3 days of hospital discharge. Direct costs per admission averaged $22,275. While late presentation was common, 133 (33%) patients had multiple health system encounters 91-180 days prior to death: early enough to be referred to an OP PC clinic. We modeled clinic costs assuming an annual volume of 50 patients, to be followed monthly for the last 4 months of life by a physician-nurse-social worker team. Annual staffing costs were estimated at $88,290. Prior research has shown that utilization of IP services in the final month of life is 40% lower amongst patients who receive early OP PC. Using that value, we estimated that providing OP PC to 50 patients annually would avoid 38 hospitalizations, with resulting avoided direct costs of $846,450. Conclusions: This feasibility study reveals that OP PC in the safety net can provide substantial return on investment, even if such services are only used by a subset of oncology patients who present earlier in their disease course.
Cost analysis of a randomized trial of early palliative care (PC) in patients with metastatic non-small cell lung cancer (NSCLC).
Authors: Greer Joseph A. , Tramontano Angela , McMahon Pamela M , El-Jawahri Areej , Parikh Ravi Bharat , Gallagher Emily R. , Pirl William F. , Jackson Vicki A. , Muzikansky Alona , Temel Jennifer S.
Published: February 2017

4

Background: Several randomized, controlled trials have shown that early, integrated palliative and oncology care improves quality of life, mood, and symptom burden in patients with advanced cancers. However, the degree to which early involvement of specialty PC in the ambulatory care setting impacts the cost of care remains unknown. We investigated the health care costs for patients with metastatic NSCLC enrolled in a clinical trial of early PC. Methods: For this secondary analysis, we examined data from a randomized trial of 151 patients with newly-diagnosed metastatic NSCLC from 06/2006 to 07/2009. Patients received either early PC integrated with standard care or standard care (SC) alone. We abstracted costs for emergency and inpatient care, outpatient visits, intravenous chemotherapy, and physician services from the hospital’s accounting system. Oral chemotherapy costs were estimated based on actual drug charges for patients. To estimate hospice costs, we used Medicare reimbursement rates. For each participant, we calculated the average total cost of care per day for the entire study period as well as the total cost of care for the final 30 days prior to death. Costs differences between groups were examined with the Wilcoxon Rank-Sum Test. Results: We analyzed health care costs of the 138 patients who died by 07/15/2013 (early PC N=68; SC N=70). The mean number of days on study was longer for patients assigned to early PC (M=397, SD=360) versus SC (M=299, SD=266). Over the study period, early PC was associated with a lower average total cost per day of $117 (SD=$436) compared to SC (p=.09). In the final 30 days of life, patients in the early PC group incurred higher total costs for hospice care (Mean difference=$1,053, SD=$3,162, p=.11), while expenses for chemotherapy were less (Mean difference=$757, SD=$2,143, p=.06). No cost differences between groups met the threshold for statistical significance. Conclusions: Although this secondary analysis was inconclusive due to the lack of statistical power to examine differences in cost outcomes, the delivery of early PC for patients with metastatic NSCLC does not appear to increase health care expenses over the course of disease or at the end of life. Clinical trial information: NCT01038271.
Barriers to palliative care in outpatient oncology practice.
Authors: Wilfong Joshua Murray , Silveira Maria
Published: February 2017

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Background: In 2009 ASCO released a policy statement recommending integration of palliative care as part of comprehensive cancer care. The various needs of cancer patients and the complex organization of health care makes this integration challenging. With this idea in mind, we conducted focus groups with oncologists and oncology nurses to identify the barriers to providing palliative care within oncology. Methods: We conducted 11 focus groups with oncologists and their nursing staff at 5 sites throughout Southeast Michigan to explore their care of patients with incurable and advanced cancer. Physicians and nurses were interviewed separately. Interviews were taped, transcribed, and analyzed using cross-case comparison. Transcripts were reviewed by multiple readers to: 1) develop a coding scheme, 2) identify themes, and 3) design an interpretive model. Results: Oncologists and their nursing staff acknowledge the importance of providing high quality palliative care to their patients. Multiple barriers that affect their abilities to provide the quality of palliative care that they desire for their patients were discussed. These issues include 1) Time limitations for discussion of symptoms and advance care plans during office visits; 2) Limited access to secondary supports (e.g. palliative care physicians, social workers, and psychiatrists) available and difficulty coordinating a timely referral; 3) Limited availability of effective case management and telephone care for coordinated patient communication between visits. Conclusions: Oncologists and their nursing staff value and acknowledge the importance of providing their patients with high-quality palliative care but multiple limitations in the organization of oncology care prevent them from doing so. Allowing longer visits, access to secondary supports, and effective case management may improve the quality of palliative care offered within outpatient oncology.
Patient-reported outcomes for determining prognostic groups in veterans with stage IV solid tumors starting systemic therapy.
Authors: Chang Victor Tsu-Shih , Scott Charles B. , Gonzalez Melanie L. , Einhorn Jan , Yan Houling , Sullivan Maryann , Srinivas Shanti , Zhong Fengming , Crump Barbara , Paz-Querubin Emma R , McPherson Monica , DeMarco Celeste , Kasimis Basil
Published: February 2017

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Background: A Recursive Partitioning Analysis (RPA) prognostic algorithm based on quality of life and symptoms predicted 4 groups with distinct median survivals in patients with metastatic solid tumors receiving chemotherapy (ASCO 2013, Abst 9567). We update our findings. Methods: The RPA algorithm is based upon Karnofsky performance status (KPS), Functional Assessment of Cancer Therapy (FACT) physical well-being (PWB) subscale, and Memorial Symptom Assessment Scale Short Form (MSAS-SF) physical symptom distress (PHYS) subscale. Starting in 2007, a convenience sample of Veterans who were prescribed systemic treatment for their cancer was enrolled in an IRB approved protocol, and completed quality of life (FACT- G) and symptom (MSAS SF) questionnaires at the first cycle of treatment. We analyzed records of patients with stage IV metastatic solid tumors enrolled through June 2013, and determined survival as of June 15, 2014. Analyses were performed with STATA 11.0. Results: There were 97 patients(pts). The median age was 64 yrs, range 27-88. Males comprised 95 (98%) pts. First line chemotherapy was given to 78 (80%) pts. The most common primary sites were lung cancer 33 (35%), prostate 17 (17%) and colon 11 (11%) pts. Median KPS was 90% range 40-100%, PWB median 23 (range 6-28), and MSAS SF median PHYS 0.76 (range 0-3.2). Overall median survival was 285 days (range 6-2,358) and 80 pts (82%) had died. There was 1 pt in group 1, 58 in group 2, 12 in group 3, and 23 in group 4. The patient in group 1 had uterine sarcoma. Median survival (days) by RPA group was 155 for group 1, 177 for group 2, 292 for group 3, and 674 for group 4 (p=.011). Conclusions: These preliminary findings suggest that this algorithm is capable of dividing patients with metastatic solid tumor who are starting systemic therapy into prognostic groups. Further development is indicated.
Joint modeling, quality of life, and survival in fast-track (or delayed-start) palliative care trials.
Authors: Li Zhigang , Frost H.R. , Yang Qian , Bakitas Marie , Tosteson Tor
Published: February 2017

49

Background: Randomized “early intervention” or “fast-track” trials (also sometimes called delayed intervention, delayed-start, or wait list designs) have been proposed as an alternative to traditional RCTs comparing palliative care interventions to non-palliative or other supportive care groups. The fast-track arm receives intervention immediately after randomization and the control arm receiving intervention after a certain period following randomization during which time standard care is provided. Such trials are more acceptable to patients, families and physicians because no one is denied access to the intervention, while still allowing for a rigorous assessment of a palliative care intervention. Many issues remain with respect to implementing such designs and analyzing the longitudinal quality of life and survival. Methods: We have developed a terminal decline model (Li et al. 2013) for jointly modeling quality of life and survival in palliative care studies. This model can be implemented on an intention to treat basis for the overall comparison in fast track design. For time periods beyond the delayed start period, we modify the model to include a time-varying treatment variable in the model to account for the treatment change in the control arm, including an interaction between the treatment and the time period. Terminal declines and quality-adjusted life years are estimated for both the intention to treat and the modified model. Results: ENABLE III is a recently completed fast-track trial in our institution at Dartmouth. After applied to ENABLE III study, the novel statistical joint modeling approach indicates that the effect of the ENABLE intervention on the terminal decline increases when combined with intervention effect seen for fast track arm. Conclusions: The terminal decline joint modeling approach is an efficient and interpretable method for fast-track study designs.
The availability of and satisfaction with palliative care services among VHA-based radiation oncologists.
Authors: Dawson George A. , Cheuk Alice V. , Jolly Shruti , Gutt Ruchika , Moghanaki Drew , Fosmire Helen , Lutz Stephen T. , Hagan Michael Philip , Anscher Mitchell Steven , Hoffman-Hogg Lori , Kelly Maria D.
Published: February 2017

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Background: Palliative care services enhance quality of life in patients with advanced malignancies and are an integral component of multidisciplinary cancer care. They provide symptom control and psychosocial support for patients and family members. A survey in non-VHA cancer centers showed that despite availability of palliative care programs, there was wide variability in the use of these services (Hui et al, JAMA 2010). Palliative care services are a component of the VHA medical benefits package. We sought to determine the ease of access to palliative care services and provider satisfaction among VHA Radiation Oncologists. Methods: VHA-based Radiation Oncologists were identified using the National VHA Radiation Oncology list serve group. All practicing Radiation Oncologists were surveyed to determine the extent of Palliative Care Services available to them and to measure their level of satisfaction with these services. Eighty two surveys were electronically mailed to practitioners at the 38 active VHA Radiation Oncology sites, followed by a reminder phone call.This survey was conducted over a four week period in May of 2014. Results: Sixty four of the 82 surveys distributed over the 4 week period, or 78% were completed. They represent 89% (34/38) of VHA Radiation Oncology Services. All respondents had Palliative Care Services available to them and 98% were happy with the services rendered by the Palliative Care teams. Conclusions: All VHA-based Radiation Oncologists who responded to this survey have access to local VHA based Palliative Care Services. This represented 82% of VHA Radiation Oncology practitioners and 98% were satisfied with the services rendered. Further studies should explore the scope and extent of palliative care involvement including when these services are integrated into the management of patients with advanced malignancies, availability of outpatient palliative care services and variations in care delivery. Radiation therapy is utilized in over 50% of patients with malignancy, often in advanced disease for symptom management and standard guidelines integrating radiotherapy and palliative care should be developed.
Using palliative care to maximize the value of care for patients with advanced cancer.
Authors: Gidwani Risha , Gale Randall , Meier Diane E. , Asch Steven M
Published: February 2017

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Background: Cancer is one of the highest cost conditions in the United States, with growth in cancer costs outpacing general medical costs. This is troubling from a patient perspective. Patients with cancer experience significantly greater financial burdens compared with patients with other medical conditions. Many patients forgo or discontinue cancer treatment partly because they do not want to burden their families with significant debt. The growth of cancer and other medical costs is also threatening the health of the U.S. economy, prompting calls for the need for high-value practices. In healthcare, value indicates an achievement of patient outcomes proportional to the resources spent to achieve them. Increasing the provision of palliative care may be one way to achieve higher value care in cancer. Methods: We summarize the literature regarding palliative care, patient outcomes, and costs to assess the value of palliative care in advanced cancer. We also review the literature to identify reasons for low patient receipt of palliative care. Results: Palliative care represents a strong opportunity to improve the value of cancer care. Palliative care is associated with better informed and more satisfied patients and families, a reduction in use of undesired medical services, and does not pose a risk of increased mortality. Reasons for low rates of palliative care include a mismatch between how patients perceive palliative care and how physicians believe patients perceive palliative care, a lack of familiarity with locally-available palliative services, and a perceived incompatibility with cancer therapy. Conclusions: Palliative care for patients with cancer can improve the patient and family experience while maximizing value for the healthcare system and averting unnecessary patient financial burden. Systems redesign is needed in order to support oncologists in supporting the palliative care needs of their patients and realizing this high-value cancer care.
Subgroup analysis of ECOG2 patients from ROMANA 2: A phase III study of anamorelin in NSCLC patients with cachexia.
Authors: Abernethy Amy Pickar , Currow David Christopher , Gleich Lyon L. , Yan Ying , Friend John , Temel Jennifer S.
Published: February 2017

6

Background: Cancer anorexia-cachexia syndrome (CACS), often observed in NSCLC patients, is characterized by decreased body weight, mainly lean body mass (LBM), and is associated with worse morbidity and survival. Anamorelin HCl (ANAM), a novel selective ghrelin receptor agonist with appetite-enhancing and anabolic activity, is in development as a treatment of NSCLC CACS. Methods: ROMANA 2 was one of two global, double-blind, Phase III trials assessing ANAM efficacy and safety in NSCLC. Patients with unresectable stage III/IV NSCLC, ECOG 0-2 and cachexia (≥5% weight loss within prior 6 months or BMI <20 kg/m2), were randomized (2:1) to 100 mg ANAM or placebo, given daily orally for 12 weeks. Co-primary endpoints were change from baseline over 12 weeks in LBM (measured by DXA) and in handgrip strength (HGS). Secondary endpoints included change in patient symptoms/concerns regarding anorexia-cachexia and fatigue (via Functional Assessment of Anorexia/Cachexia Treatment [FAACT] and Functional Assessment of Chronic Illness Therapy – Fatigue [FACIT-F]). Safety assessments included lab values and adverse events (AEs). This pre-specified analysis focused on ECOG2 patients. Results: ROMANA 2 (N=495) enrolled 130 ECOG2 patients (N=41 placebo; N=89 ANAM). Subgroup demographics were balanced: median age= 64 yr, male (81.5%), metastatic (74.6%), and prior weight loss >10% (61.5%). In the overall trial, ANAM significantly increased LBM vs placebo (0.75 vs -0.96 kg; p<0.0001) and improved FAACT over 12 weeks (3.48±0.9 vs 1.34±1.0; p=0.0016); change in HGS was not statistically different. In the ECOG2 subgroup, ANAM also significantly increased LBM (0.45 vs -2.66 kg; p=0.0004); there was a trend towards improvement in FAACT and FACIT-F but this was not statistically significant. In the ANAM arm of the ECOG2 subgroup, the most frequent drug-related AE was hyperglycemia (4.5%), with few (1.1%) drug-related Grade ≥ 3 AEs. Conclusions: ANAM treatment for 12 weeks was well tolerated. In patients with ECOG2 performance status, which represents a more severe/fragile population, ANAM improved LBM, as well as anorexia-cachexia and fatigue symptoms/concerns in advanced NSCLC cachectic patients. Clinical trial information: NCT01387282.
Developing a new model of care for patients with cancer who present to the emergency department: The Mayo Clinic experience.
Authors: Wong Debra A. , Fitch Tom R. , Prommer Eric , Chang Yu-Hui , Lipinski Christopher A.
Published: February 2017

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Background: Patients with cancer often have complex symptoms and morbidity that prompt frequent Emergency Department visits. The length of stay in the ED for cancer patients exceeds that of patients without cancer. Patients with cancer are also more likely to be admitted, but are often discharged within 72h. Protracted ED visits, extensive investigations, and the burdens of even a short admission may be distressing and may not be aligned with patients’ care goals and preferences. Furthermore, the healthcare resources dedicated to these patients is considerable and has economic implications. We recently established a Supportive Care Infusion Center (SCIC), an on-campus outpatient unit where patients can receive treatments for symptom relief and comfort; they are assured integrated palliative care with routine oncologic care. We believe there is a subset of cancer patients who can be safely transferred from the ED to the SCIC for appropriate care. Methods: We are retrospectively evaluating cancer patients admitted through the ED to validate clinical parameters likely to lead to admission, and also identify any differences between patients admitted for <72h vs >72h. Patients are analyzed based on symptoms, cancer type, prior cancer therapies, performance status, comorbidities, and presence/absence of advance care planning as well as previous contact with Palliative Care. Data are also being gathered on patient outcomes, including mortality within 60d of admission. Results: Previously established indicators predictive of admission included shortness of breath and SIRS criteria, which our current review validates. We also observe that patients admitted for >72h have greater symptom burden and comorbidities and have received multiple lines of therapy. They also less frequently have advance care planning in place. Data analysis is ongoing. Conclusions: There exists a difference between cancer patients admitted >72h and those discharged within 72h. Awareness of these characteristics may lead to improved workflow in the ED. Identifying patients who may be suitable for transfer to an outpatient supportive care unit rather than short-term admission will also facilitate cost-effectiveness. Future direction includes evaluation of outcomes such as mortality, quality of life, and patient-caregiver satisfaction.
Do newly diagnosed cancer patients require palliative care? An audit at a regional cancer center in India.
Authors: Ghoshal Chakrabarti Sushmita , Miriyala Raviteja , Elangovan Arun , RAI Bhavana
Published: February 2017

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Background: The present study was planned to record the distressing symptoms of newly diagnosed cancer patients and to evaluate how the symptoms were addressed by the treating oncologists. Methods: All newly diagnosed cancer patients referred to the department of Radiotherapy during the month of May 2014 were asked to fill a questionnaire after taking their consent. The ESAS-r questionnaire was used to assess the frequency and intensity of distressing symptoms. The case records of these patients were then reviewed to compare the frequency and intensity documented by the treating physician. The difference in the two sets of symptoms documented were statistically analysed by non-parametric tests using SPSS. Results: Eighty-nine patients participated in this study out of which only 19 could fill the questionnaire on their own. Anxiety was the commonest symptom (97.8%) followed by depression (89.9%), tiredness (89.9%) and pain (86.5%). The treating physicians recorded pain in 83.1% while the other symptoms were either not documented or grossly under reported. Anxiety was documented in 3/87 patients but depression was not documented in any. Tiredness was documented in 12/80 patients, loss of appetite in 54/77 patients mentioning them in the questionnaire. Significant statistical correlation could be seen between the presence of pain, anxiety, depression, tiredness and loss of appetite in the patients. Conclusions: The study reveals that the distressing symptoms experienced by newly diagnosed cancer patients are grossly under reported and inadequately addressed by treating oncologists. Sensitizing the oncologists and incorporating palliative care principles early in the management of cancer patients could improve their holistic care.
The Orkdal model: Development, implementation, and evaluation of collaboration between specialist and community care within cancer palliative care.
Authors: Brenne Anne-Tove , Knudsen Anne Kari , Brunelli Cinzia , Halsteinli Vidar , Kaasa Stein
Published: February 2017

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Background: Palliative care early in the cancer disease trajectory may improve health related quality of life for patients and their families. Collaboration between community and specialist health care professionals is paramount to achieve optimal cancer care. The objective of this study is to develop and to implement this model into our health care system.The target population is cancer patients with metastatic and/ or loco-regional disease. Methods: The study takes place in a rural district of 13 municipalities with a local hospital (Orkdal) in Mid Norway. It is designed as a prospective controlled observational pre- post cohort study with four main interventions: 1. Development and implementation of a standardized care pathway across health care levels, 2. Educational programme for health care professionals, 3. Information about cancer and palliative care to the public, 4.Information,education and support to family members.Outcomes are patient’s time spent at home, family member’s health related quality of life, improvement of health care providers’ knowledge and skills and distribution of health care service use. Results: A standardized care pathway for all palliative cancer patients including home care, care in nursing homes, and specialist care in hospitals (in- and outpatients) is developed. It focuses on access to palliative care services, transfer of medical data, and symptom assessment. The educational program consists of two parts; one to inform about the project and the standardized care pathway, and one to improve competence and skills in cancer palliative care. To the general public, information regarding chemo- and radiotherapy, symptom diagnosis and treatment and palliative care services in general is given. Conclusions: A total integrated model to improve care for cancer patients was developed focusing on collaboration between community and specialist health care, and on early integration of palliative care in the traditional cancer care trajectory. Improved care for cancer patients and their families in the Orkdal region to equal costs is expected. The Orkdal Model may be applied in other regions and for other chronic diseases. Clinical trial information: NCT02170168.
The sooner the better: Analysis of proactive palliative medicine consultation in the medical intensive care unit amongst patients with stage IV malignancy.
Authors: Levine Shanna R , Bridget Earle I , Edwards Wendy S.A.
Published: February 2017

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Background: Palliative care has been shown to improve quality of life and prolong median survival in patients with advanced cancer. Sadly, patients are still suffering at the end of their lives perhaps secondary to aggressive hospital care. ICU use in the last month of life increased from 24.3% to 29.2% over the last study decade. Our objective was to evaluate and quantify outcomes, including survival, of patients with active stage IV malignancy admitted to an urban university affiliated hospital MICU who had a palliative medicine consult. Methods: A retrospective chart review of patients from 04/2013 - 04/2014 admitted to the MICU with active stage IV malignancy identified via a validated proactive case finding trigger tool. The trigger was based on eight criteria, one of which being active stage IV malignancy. The MICU census was reviewed biweekly. Data collected included pain and symptom relief, clarification of goals of care, length of stay, and disposition (hospice, rehabilitation facility, home and death). Results: Four hundred sixty eight patients were assessed. One hundred and twenty two patients met 1 of the 8 criteria, and 24 patients met the inclusion criteria for review. Three patients were not seen due to attending and/or family preference. Thirty eight percent of patients had improved symptoms and management control, 42% had clarification of goals of care and medically appropriate decision making, and 42% experienced psychosocial spiritual counseling. Eight patients died during their hospital stay, 4 were transferred to inpatient hospice facilities, 3 to rehabilitation facility, 2 went home and the remainder was “other”. The average length of stay of patients seen by palliative care was 20 days compared to 31 days for patients not seen by the palliative team. Conclusions: Nearly 40% of patients with active stage IV malignancy admitted to the MICU died during their hospital stay. We believe this study illuminates the futility of ICU care in this patient population. Consultation from the palliative medicine team using a proactive trigger tool can be beneficial to allow for better symptom control, clarification of goals and psychosocial counseling.
Timely education about palliative care (PC) among pancreatic cancer patients.
Authors: Grenon Nina N. , Sommer Karen A. , Barysauskas Constance
Published: February 2017

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Background: A majority of cancer patients only receive PC at the end-of-life despite the physical, emotional, and existential distress throughout the continuum of the disease. The literature suggests early PC combined with standard care, improves quality of life and potentially extends survival. A four month retrospective chart review of patients diagnosed with pancreatic cancer at Dana-Farber Cancer Institute (DFCI) revealed only 19% of patients had a documented PC educational conversation within the first four weeks of care. Although early incorporation of PC education is imperative for patient quality of care it is not taking place. Methods: A quality improvement project was designed to increase the number of documented PC discussions among all new locally advanced and metastatic pancreatic cancer patients who were followed at the DFCI for the first four weeks of care. An educational brochure about PC was developed for providers and providers were educated about PC at a monthly staff meeting after completing a brief survey. Providers received an email reminder for all eligible patients and the PC brochure was attached to all patient encounter forms. Follow-up chart audits were conducted and pre and post surveys were administered to patients. Results: Providers and patients indicated no barriers to PC education. Providers indicated the onset of difficult to manage symptoms as the appropriate time to discuss PC and patients indicated first treatment or first treatment failure as the appropriate time to discuss PC. Chart audits revealed all eligible patients were educated about PC between April 14 and May 9, 2014 (n=13). Conclusions: Following implementation of this successful initiative, all eligible patients were educated about PC, conversations were documented and providers identified no barriers in the process. Due to the small scope of this project, further work is needed to improve sustainability, including ongoing identification of the number of patients who enroll in PC services concurrently with standard care, measure patient satisfaction, and implement our initiative in additional disease centers. In the future, infusion nurses, practice nurses, and social workers will participate in PC education training.
Care of the caregiver: Improving caregiver outcomes across the disease trajectory.
Authors: Page Margaretta , Molina Idonah M. , Patt Judy , Chang Susan Marina
Published: February 2017

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Background: Caregivers are essential members of the health team, often assuming diverse primary care roles for the cancer patient. Caregiver needs vary across the trajectory of illness and range from informational needs to emotional support to assistance with accessing resources. The needs of caregivers of brain tumor patients are complex not only because of the life threatening nature of the illness but also because of the wide range of neurological and cognitive deficits patients experience, a known risk factor for added stress to the caregiver. To address these challenges and improve caregiver outcomes, the Neuro Oncology Division at UCSF developed a program to provide an additional layer of care that includes information and support to caregivers of brain tumor patients across the trajectory of illness, from diagnosis to death. Methods: The program consists of a medical director and a dedicated nurse practitioner, social worker and coordinator, all focused on the caregiver of the brain tumor patient. The goals of the program are to provide information needed to assist with disease and symptom management, effective communication with the health care team, maximization of use of available resources, and to provide emotional support. Three groups of caregivers were targeted: caregivers of all new patients with a focus on newly diagnosed glioblastoma and caregivers of patients deemed at “high risk,” either identified by the provider, or because of the phase in the illness trajectory. Results: Since June 2013, 13 caregivers reported no needs for the first 4 months from diagnosis. 13 caregivers received care, with over half reporting concerns regarding financial issues and disability as well as need for emotional support around adjusting to the diagnosis, role changes, and care demands. In addition, varying levels of care have been provided to 70 caregivers of patients identified at “high risk” for distress due to disease progression or when transitioning to hospice. Conclusions: This program provides care to caregivers of brain tumor patients at specific time points to improve caregiver outcomes. Challenges include tailoring the information at the right time as well as measuring outcomes with minimal extra burden to the caregiver.
Patient evaluation of a physician conveying a more optimistic versus a less optimistic message: A randomized controlled trial.
Authors: Tanco Kimberson , Rhondali Wadih , Perez-Cruz Pedro Emilio , Tanzi Silvia , Chisholm Gary B. , Baile Walter F. , Sisson Amy , Arthur Joseph , Bruera Eduardo
Published: February 2017

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Background: Information regarding treatment options and prognosis is essential for patient decision making near end of life. However, physicians are frequently reluctant to deliver bad news due to multiple factors, including fear of being perceived as less compassionate. This randomized controlled double blind trial aimed to examine the patient’s perception of physician compassion after being exposed to a more optimistic vs. a less optimistic message. Methods: 100 patients were randomized to observe 2 standardized videos, depicting a physician discussing treatment and prognostic information (more optimistic message and less optimistic message) with a patient with advanced cancer. Both physicians displayed identical number of empathetic statements (5) and posture. Three sets of surveys were completed including the Physician Compassion Questionnaire (0=best, 50=worst). Actors and patients were blinded to the purpose of the study. Investigators were blinded to the video observed by the patient. Results: Patients reported significantly better compassion scores after watching the more optimistic video as compared to the less optimistic video [median (Q1-Q3): 15 (5-23) vs. 23 (10-31), p=0.0002]. Results were equally significant after parallel analysis of first video only and after cross-over analysis. There was also an order effect with compassion scores (p=0.0002) favoring the second video. Univariate analysis showed that degree of trust in the medical profession, ESAS fatigue, ESAS anxiety and ESAS depression had significant association with compassion perception independent of message observed. After applying Bonferonni correction, only degree of trust in the medical profession reached the corrected p value of p=0.0014 (p=0.0002). Conclusions: A more optimistic message resulted in a physician being perceived as more compassionate by the patient. The physician seen in second order is also perceived to be more compassionate. More research is needed to better understand patient perception of compassion in communication with physicians.
“Allow natural death” versus “Do not resuscitate”: What do patients with advanced cancer choose?
Authors: Miljkovic Milos , Emuron Dennis Omoding , Rhodes Lori , Abraham Joseph , Miller Kenneth David
Published: February 2017

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Background: Many patients with advanced cancer at our hospital request full resuscitative efforts at the end of life. In the first in a series of quality improvement projects to improve end-of-life (EOL) care, we assessed the knowledge and attitudes of patients towards it to determine if “Allow Natural Death” (AND) orders were more acceptable than “Do Not Resuscitate” (DNR) orders. Methods: Adult patients with advanced cancer being treated at a single community hospital were invited to participate. The first 100 consenting patients were surveyed regarding their diagnosis, prognosis, and attitudes about critical care and resuscitation. They were then presented with hypothetical scenarios in which a decision on their code status had to be made if they had 1 year, 6 months or 1 month left to live. Fifty patients were given a choice between being “full code“ and “DNR”, and 50 could choose between ”full code" and “AND”. Results: Participants were equally likely to choose either of the “no code” options in all hypothetical scenarios (p > 0.54). The choice was not affected by age, sex, race, type of cancer, education, or income level. Patients who said they would want life-prolonging measures such as CPR, tracheostomies, and feeding tube placement in case of a permanent vegetative state were significantly less likely to choose “AND” than “full code” (p=0.001–0.002). A similar proportion of patients who had a living will chose “AND” and “DNR” orders instead of “full code” in all the scenarios (47–74% and 63–71%). In contrast, among patients who did not have a living will 52% chose “DNR”, while 19% opted for “AND”. More than a third (39 of 93) patients were not aware their illness was terminal. Conclusions: We hypothesized that “AND” orders may be more acceptable to patients with advanced cancer, but the wording of the “no code” order does not seem to be related to the patients’ code status decisions. The “Do not resuscitate” phrasing may be more acceptable to patients who view life-prolonging measures favorably.