bluuebunny/crossref_metadata_2025 huggingface dataset:
Are patients with triple-negative breast cancer screened for BRCA mutations according to NCCN guidelines?
Authors: Aubry Staci , Petersen Lindsay Floch , Burgess Kelly , Rao Ruta D. , Kopkash Katherine , Madrigrano Andrea
Published: February 2017

7

Background: Ten to 25 percent of patients diagnosed with breast cancer have triple negative breast cancer (TNBC), defined as tumors negative for estrogen, progesterone, and Her2-neu receptors. TNBC is more aggressive than receptor positive cancer. The National Comprehensive Cancer Network (NCCN) recommends BRCA genetic testing for women less than age 60 when diagnosed with TNBC. Methods: The Commission on Cancer registry tumor database was queried for TNBC from 2006 to 2013. Patient demographics were analyzed. Data regarding pathologic details and BRCA testing was collected. Analyses using the Fisher's exact test were conducted. Results: TNBC tumors were identified in the database (n = 173). Sixty-one percent (105/173) of patients were less than 60 years of age, therefore BRCA testing was indicated. Fifteen patients were BRCA positive. Eighty-three percent (87/105) of patients underwent BRCA testing. Seventeen percent (18/105) of patients did not receive BRCA testing that should have under the current guidelines. Patients that did not undergo recommended BRCA testing were more likely to be greater than or equal to 55 years of age (p = 0.002), African-American (p = 0.001), have Medicaid listed as a primary payer (p = 0.021), and have American Joint Commission on Cancer (AJCC) stage 3 disease (p = 0.014). Conclusions: Risk factors for not completing BRCA testing include older age, African-American race, Medicaid insurance status, and stage 3 disease. Health provider awareness of this opportunity for improvement is important to decrease these health disparities. [Table: see text]
Adherence to osteoporosis screening guidelines in seniors with breast cancer treated with anti-estrogen therapy: A population-based study.
Authors: Henault David , Chang Sue-Ling , Dumitra Sinizana , Kramer Richard , Mayo Nancy , Meguerditchian Ari
Published: February 2017

72

Background: Aromatase inhibitors (AI) improve recurrence and survival rates in women ≥ 65 with hormone-receptor positive (HR+) breast cancer (BC). However, AI’s are associated to increased bone demineralization in a population already at risk for osteoporosis. Bone mineral densitometry (BMD) is therefore recommended at treatment start, to minimize treatment-related toxicity. This study assesses compliance to BMD recommendations in older BC survivors treated with an AI and identifies predictors of non-adherence to guidelines. Methods: A population-based historical prospective cohort study was conducted in Quebec (Canada), where universal health insurance provides medical and pharmaceutical services. All women ≥ 65 with incident stage I, II or III BC (1998-2012) were identified from the provincial cancer registry. Administrative claims were accessed to track receipt of BMD (±12 months from treatment start) and potential predictors: age, economic status, Charlson comorbidity index, breast and axillary surgery, chemotherapy, radiotherapy, bisphosphonate use, adherence to anti-estrogen therapy (AET), physician specialty and having a primary care physician (PCP). Multivariate logistic regression was performed using generalized estimating equations to identify predictors of BMD, adjusting for clustering within physicians. Results: Of 16,480 patients, 36.1% had a BMD at AET start. This increased to 58.4% for women on AI. Factors predicting baseline BMD non-use in AI patients were: older age (OR 0.42; 95% CI, 0.36 – 0.49), lower annual income (OR 0.57; 95%CI, 0.47 – 0.70), not having a PCP (OR 0.77; 95%CI, 0.68 – 0.86), chemotherapy and radiotherapy outside of guidelines (OR 0.80; 95%CI, 0.66 – 0.96 and 0.69; 95%CI, 0.54 – 0.87, respectively), non-surgical specialist managing AET (OR 0.81; 95%CI, 0.67 – 0.98), older physicians (OR 0.61; 95% CI, 0.46 – 0.81), and non-adherence to AET (OR 0.69; 95%CI 0.60-0.79). The same predictors persisted in patients on any AET. Conclusions: Bone health management in seniors receiving AET is suboptimal. Factors related to underutilization of BMD can be easily identified and used to optimize chronic care of older BC survivors.
A misperceived threat: Understanding the increasing mastectomy rates.
Authors: Covelli Andrea Marie , Baxter Nancy N. , Fitch Margaret , Wright Frances Catriona
Published: February 2017

75

Background: Rates of unilateral (UM) and contralateral prophylactic mastectomy (CPM) for early-stage breast cancer (ESBC) have been increasing. Both surgeons’ preference and patients’ choice have been suggested to play a role. Methods: A qualitative study was conducted examining surgeon’s practices and patient’s decision-making during treatment for ESBC. The Health-Belief Model was applied identifying factors influential in the choice for UM+/-CPM. Purposive sampling identified non-high-risk women across Toronto, Canada who were candidates for breast conserving therapy (BCT) but underwent UM+/-CPM. Academic and community breast surgeons from across Ontario, Canada and the United States were also recruited. Data were collected through semi-structured interviews. Constant comparative analysis identified key ideas. Results: 29 patients and 45 surgeons were interviewed. The dominant theme was the ‘misperceived threat of ESBC: an overestimated risk’. Surgeons described the high survivability of ESBC, yet patients greatly overestimated the threat of death from their cancer and strived to eliminate this threat by choosing UM+/-CPM. Surgeons described BCT and UM as equivalent treatment options for ESBC, and recommended BCT. In this average-risk population CPM was discouraged by the surgeons describing no survival advantage; despite this, women requested UM+CPM. Personal cancer experiences with family and friends were extremely influential in women’s request for UM+/-CPM. Previous negative experiences translated into an overestimated risk of recurrence, contralateral cancer, metastasisand subsequent death. Patients’ misperceived the severity of ESBC, and believed that by choosing UM+/-CPM they would live longer. Most women did not perceive any risks of undergoing mastectomy, yet many had ongoing issues with skin sensation, cosmesis and body image. Conclusions: Despite surgeons counseling otherwise, women greatly overestimated the risk of ESBC and misperceived the benefits of mastectomy. As undergoing UM+/-CPM is not without risks, improved discussion of patient sources of information and fears around survival may benefit surgical consultations, facilitating informed decision-making.
Characteristics of chemotherapy-induced peripheral neuropathy in patients with breast cancer.
Authors: Sawada Namie Okino , Zandonai Alexandra Paola
Published: February 2017

85

Background: In Brazil, breast cancer has the second highest incidence of neoplasms, the most common among women. It is expected there will be 57,120 new cases and a risk 56.09 cases per 100 thousand women. For its treatment, neurotoxic chemotherapeutics that can cause chemotherapy-induced peripheral neuropathy (CIPN) are used. Methods: This is an exploratory descriptive study developed in a cancer treatment reference hospital in the city of Sao Paulo, Brazil. Aim: To search the patients with breast cancer during treatment with neurotoxic agents and evaluate the presence of CIPN with application of Chemotherapy-Induced Peripheral Neuropathy Assessment Tool questionnaire (CIPNAT). Results: The sample was 44 women with a mean age of 52 years (SD = 10.54), 47.7% had local disease, 72.7% were treating with taxanes neurotoxic agents. The main neuropathic symptoms measured at CIPNAT: 75% had motor symptom weakness with an average score for severity of 6.45 causing an average of distress 5.36; 65.9% muscle and joint pain average severity of 6.31 causing an average of 5.59 distress; and 56.8% sensitive symptom numbness in the hands average severity of 4.76 causing an average of 3.52 distress. These symptoms had a negative impact in the activities of daily living (ADL) such as physical exercise (mean score = 5.32), enjoyment of life (mean score = 4.77) and leisure activities (mean score = 4, 03). Although few (13.6%) reported that suffered some injury or accident due to CIPN. Discussion: The results are consistent with those presented in the scientific literature, but measured with other assessment tools such as the NCI CTCAE, WHO and EORTC QLQ-C30 and CIPN20, which also showed that motor disorders (weakness, muscle cramps and loss of strength in the hands) and sensory (numbness and tingling in the hands and feet). Conclusions: The study explores the relationship between CIPN and ADL affected during treatment for breast cancer. Through the motor and sensory symptoms reported by CIPNAT, nursing will have grant to develop educational strategies to prevent and minimize negative impacts on the quality of life of women with breast cancer undergoing treatment with neurotoxic agents.
Role of neutrophils in the early presymptomatic stages of doxorubicin cardiotoxicity in breast cancer.
Authors: Todorova Valentina K , Beggs Marjorie L , Siegel Eric R , Makhoul Issam , Wei Jeanne , Klimberg V. Suzanne
Published: February 2017

98

Background: Doxorubicin (DOX) cardiotoxicity is cumulative-dose-dependent and begins with the first dose of chemotherapy. No biomarker for early presymptomatic detection of DOX cardiotoxicity has been validated. Our preliminary microarray-based study on DOX cardiotoxicity of breast cancer patients showed that neutrophil-associated inflammation was partly responsible for this side effect of DOX Based on our preliminary finding, the aim of this study was to examine the expression of the top dysregulated neutrophil-specific genes, including alpha-defensins, arginase, cathepsin G, elastase, haptoglobin, metalloprotease 9, cathelicidin 8 in the peripheral blood mononuclear cells (PBMCs) of breast cancer patients treated with DOX-based chemotherapy. Methods: Blood samples of 15 women treated for breast cancer with DOX-based chemotherapy were collected before the start and after the 1st cycle of chemotherapy. Cardiac function was assessed before the start and after the completion of chemotherapy. A decrease of left ventricle ejection fraction (LVEF) > 10% or < 55% was considered abnormal. PBMC gene expressions of the target genes were assessed by quantitative RT-PCR and normalized to 18S. Data were analyzed using 2-deltadelta CT method and compared between patients with abnormal versus those with normal LVEF. Results: A single dose of DOX-based chemotherapy induced significantly greater mRNA levels of the examined genes in PBMC of patients with subsequent abnormal decline of LVEF (n = 5) versus those patients who maintained a normal LVEF. The elevated neutrophil-associated transcripts in the early stages of DOX-based chemotherapy were independent of the neutrophil count. Conclusions: We have identified a set of transcripts in the early stages of DOX-based chemotherapy that can serve as biomarkers for prediction of later impairment of cardiac function in breast cancer patients. Biomarkers for early prediction of DOX-induced cardiotoxicity could allow individualization of chemotherapy and/or testing the effectiveness of cardio-preventive medication, and ultimately will help to reduce the incidence of the cardiotoxicity-associated morbidity and mortality in cancer survivors.
Symptoms associated with circadian rest-activity rhythm disruption in 237 patients with metastatic colorectal cancer.
Authors: Innominato Pasquale F. , Palesh Oxana , Bjarnason Georg A. , Ulusakarya Ayhan , Spiegel David , Levi Francis
Published: February 2017

1

Background: The circadian timing system exerts temporal control over physiology, generating rhythms of about 24 hours. Its alteration in benign conditions has been associated with several systemic symptoms, including fatigue, appetite loss and poor sleep. However, the clinical impact of circadian disruption in cancer patients remains overlooked. We hypothesized that patients with circadian disruption would report more severe symptoms than those with robust circadian function. Methods: Data were available for 237 patients with metastatic colorectal cancer: M/F ratio: 1.66; median age: 60.4 years; range: 20.7-77.6; WHO Performance Status (PS) = 0/1: 59.7%/33.5%. We estimated the occurrence of circadian disruption using a validated parameter (the dichotomy index I < O), derived from wrist-actigraphy for at least 72 consecutive hours. Symptoms were self-reported by the patients using the EORTC QLQ-C30 questionnaire. Mann-Whitney U test was used to compare symptom severity according to the presence or absence of circadian disruption. Cohen’s d effect sizes were computed to evaluate the clinical meaningfulness of the observed differences. Subgroup analyses were performed according to gender, age, and WHO Performance Status (PS). Results: Circadian disruption (I < O lower than or equal to 97.5%) occurred in 130 (54.9%) patients. Fatigue (p < 0.0001), appetite loss (p < 0.0001), difficulty sleeping (p = 0.009), pain (p < 0.0001) and dyspnea (p = 0.001) were significantly more severe in patients with circadian disruption than in those with robust circadian function. Largest effect sizes were observed for fatigue (0.64), appetite loss (0.59) and pain (0.57). Subgroup analyses showed similar results, regardless of gender, age or PS. Conclusions: In this large international study, the presence of circadian disruption was associated with a clinically meaningfully higher severity of fatigue, appetite loss, pain, dyspnea and sleep problems. Correcting circadian dysfunction with the use of pharmacological and/or behavioural interventions could improve these often difficult-to-manage systemic symptoms.
Palliative care and hospice use among melanoma patients treated with immunotherapy.
Authors: Nipp Ryan David , Betof Allison Shayna , Rubin Krista M. , Blackmon Shauna M. , Flaherty Keith , Lawrence Donald P. , Sullivan Ryan J.
Published: February 2017

116

Background: PD-1/PD-L1 inhibitors (PD-1/PD-L1i) have revolutionized the treatment of patients with metastatic melanoma. However, little is known about the supportive care needs and use of palliative care (PC) services in these patients. We sought to assess rates and correlates of PC consultation and hospice use among melanoma patients treated with PD-1/PD-L1i. Methods: We retrospectively collected data on all patients with melanoma treated with PD-1/PD-L1i at the Massachusetts General Hospital (MGH) from May 2009 to March 2015. We determined rates of PC consultation and hospice use in this sample. We used logistic regression with purposeful selection of covariates to identify correlates of PC consultation. Results: Of 122 patients treated at MGH (mean age = 61.2 years), most were married (n = 91, 75%) and college educated (n = 66, 54%). Overall, 83 patients (68%) experienced autoimmune toxicities, 22 (18%) had liver metastases, 87 (71%) had cancer progression and 44 (36%) died during our study period. We found that 36 patients (30%) received PC consultation during their treatment course; 9 (25%) of these occurred over 6 months prior to the patients’ death, and 11 (31%) in their last month of life. Among the patients who died, 36 (82%) received hospice services, and 11 (31%) enrolled in hospice during their last week of life. In our regression model, younger age, having cancer progression and presence of liver metastases correlated with increased likelihood of receiving PC consultation. Conclusions: Melanoma patients treated with immunotherapy often receive PC and hospice services late in their treatment course. These data underscore the difficulty understanding when to involve hospice and PC for these patients, and highlight the need for further PC research in this patient population. Additionally, younger age, presence of cancer progression and liver metastases were associated with receiving PC consultation, thus suggesting the need for integrated PC services among certain subpopulations of these patients. [Table: see text]
Variations in use and timing of hospice and palliative care: Differences across health care payers and cancer type.
Authors: Gidwani Risha , Joyce Nina , Kinosian Bruce , Levy Cari , Faricy-Anderson Katherine E. , Ersek Mary , Miller Susan , Mor Vincent
Published: February 2017

132

Background: Cancer societies recommend cancer patients receive palliative care soon after diagnosis of illness and hospice for at least 3 days before death. While studies suggest receipt of hospice in the last 3 days of life is increasing for patients, the timing of first hospice and first palliative care is currently unknown. It is also not known whether fee-for-service versus capitated healthcare systems differ in their provision of supportive care. We evaluated the timing and frequency of palliative care and hospice use across the Department of Veterans Affairs (VA) and Medicare for dually-eligible Veterans, to understand variations in the use and timing of these services across healthcare systems for the same patient population. Methods: A retrospective evaluation of all VA and Medicare administrative data for the population of Veterans aged 65 or older who died with advanced cancer in 2012. Results: The majority of Veterans received supportive care before death: 67% received hospice and 69% received palliative care. On average, patients had 2 encounters with palliative care before death. Patients with melanoma were most likely to receive palliative care (82%); patients with hematologic malignancies were least likely to receive palliative care (58%). Veterans received VA-based hospice on average 35 days before death (SD = 42), while Veterans receiving Medicare-based hospice did so an average of 25 days before death (SD = 24). However, across both systems, 50% of Veterans were receiving hospice 16 days before death. There were substantial variations in timing of hospice enrollment by cancer type. Of Veterans receiving VA- or Medicare-based hospice, 22% cycled in and out of hospice, meaning they dis-enrolled and re-enrolled in such care. 16% of patients were discharged from hospice before death, with VA more likely to discharge Veterans before death compared with Medicare. Conclusions: There are large variations in healthcare system approaches to timing and use of hospice and palliative care, as well variations by cancer type. VA provides hospice to patients earlier in the disease trajectory, while Medicare is more likely to have patients die while enrolled in hospice.
Pushing palliative care upstream: Integration into a community-based oncology practice.
Authors: Blechman Jennifer , Bull Janet
Published: February 2017

134

Background: It is now well established that palliative care is an integral part of cancer treatment, recommended by the National Cancer Comprehensive Network for evidence based practices. Palliative care in this setting has been shown to improve symptom burden, enhance quality of life, reduce cost, and extend survival. Partners in Care is a non-profit, community-based hospice/home health agency in Bend OR, and consistent with national trends, receives late oncology referrals to hospice. Partnership with a multispecialty group was established to allow for a palliative care specialist to be embedded into their oncology clinic. Methods: Palliative care consults are offered 2 days/week in the oncology clinic. Triggers have been created to facilitate consultation. Quality metrics have been carefully tracked and include symptom scores, advance care planning, and transition and length of stay for hospice referrals. Financial support has been provided through grant funding from local insurance and community foundations. Results: In the first 10 months, 116 new oncology patients were seen, and had an average 1.9 visits. Documented ACP discussions occurred in 85% patients. Of patients with moderate to severe pain and dyspnea, scores improved by 65% and 50% respectively. Length of stay on hospice increased from 26 to 36 days. All of the patient respondents surveyed would recommend our service to others. Provider respondents 100% strongly agree that objectives were met when they requested a palliative care consult. Conclusions: Palliative care has been successfully integrated into a community-based oncology practice, resulting in increased access to palliative care, increased utilization of and length of stay on hospice, improved symptom management, increased use of ACP, and enhanced patient/family satisfaction. Having palliative care embedded in the clinic has resulted in better coordination of care and ease of communication. Future directions include using QDACT (Quality Data Collection Tool) to better track quality measures, inclusion of a social worker, and alignment with insurers and ACOs for cost support and data analytics.
Engaging the cancer care team in advance care planning.
Authors: Mahmood Tallat , Severson Jane Alcyne , Thompson Laura
Published: February 2017

14

Background: Engagement of oncologists and their care team is essential to ensure advance care planning (ACP) occurs for cancer patients. However, numerous barriers to ACP exists, including the availability of trained staff with competence and confidence to have discussions with patients as well as resources to ensure ACP is effectively and efficiently integrated into the oncology practice. Methods: A baseline audit to determine the presence of documented ACP discussions for patients with metastatic cancer was conducted, followed by a quality improvement program with subsequent reassessment. The baseline audit identified only 20% (10/50) compliance with documentation of such discussions. Subsequently, we joined the Michigan Oncology Quality Consortium’s (MOQC) ACP Collaborative where the care team (MA, RN, PA, MD) were taught how to request and complete a durable power of attorney, conduct ACP conversations, and document pertinent information in a standard EHR location. Results: A one-year post-intervention audit found that 80% (40/50) of patients with metastatic cancer had an ACP documented in their record - a four fold improvement. A post-implementation staff survey noted that the team improved their understanding of both the legal issues and importance of asking about advance directives as well as using the designated chart location to document. 100% of staff agreed or strongly agreed with the statement “I understand the importance of asking patients about advanced directives”. Staff gained confidence in how to talk to patients about advance directives again with 100% of staff agreeing or strongly agreeing with the statement,” I feel more confident now in how to talk to a patient about advanced directives”. Conclusions: It is critical that all members of the oncology care team understand the importance of ACP and that staff feel confident in how to have discussions with patients. While physician/patient discussion is both necessary and expected, patients often discuss their wishes and fears with others in the practice. It is critical that all members of the team understand the importance of and opportunities where they can both support patients’ wishes and direct patients to their oncologist if necessary for further discussion.
Characteristics of patients referred to embedded rapid access supportive care clinic.
Authors: Yennu Sriram , Lu Zhanni , Williams Janet L. , Arthur Joseph Anthony , Bruera Eduardo
Published: February 2017

141

Background: ASCO recommends Palliative care and Oncology integration to improve quality care outcomes. There is limited data on the patient (pt) characteristics (PC) for those who access integrated care. Our center created a pilot rapid access supportive care clinic (RASCC) to facilitate same-day consultation. The aim of this study was to determine the PC of pts referred (R) and not referred (NR) to RASCC. We also examined the PC of those who referred early[ER] (within 12 weeks of diagnosis or registration) vs those who have referred late [LR]. Methods: We reviewed pt medical records of all pts R and NR during the pilot period (Aug 01, 2012 to June 30, 2013). To be eligible all pts had advanced Stage IV non-small cell lung cancer with oncologist estimated overall survival (OS) of ≤ 6 months. Results: Of a total of 419 eligible pts seen at the thoracic oncology clinic, 157 (37%) pts were referred to RASCC. R group had a higher symptom distress scores, SDS (Table 1), weight loss, worse PS and OS compared to NR. There was no difference in PC between ER and LR except in the ESAS symptoms and SDS scores were higher in ER than LR, 40(29.5,52) vs 31.5(22.25,40.125), P < .001. Conclusions: R pts had higher symptom burden and worse OS. Similarly ER had a higher SDS than LR suggesting referrals to RASCC were primarily based on symptom burden. [Table: see text]
Barriers to goals of care discussions with patients with advanced cancer and their families: A multicenter survey of oncologists.
Authors: Ethier Josee-Lyne , Paramsothy Thivaher , Gandhi Sonal
Published: February 2017

15

Background: Early documentation of end-of-life (EOL) preferences in patients with advanced cancer is associated with less aggressive EOL care, however, several barriers to having these discussions exist. Evaluating practitioner-level barriers in the ambulatory oncology setting by adapting an existing survey from the critical care and internal medicine contexts was deemed important. Methods: The previously published “DECIDE” survey was modified to the ambulatory oncology setting and pilot tested. Surveys were then distributed to oncologists in Ontario, Canada via paper and secure online methods. The survey asked physicians to rank on a numerical scale the importance of various barriers to having EOL discussions with patients and their families. Trends were established using descriptive statistics. Analysis by respondent demographic was not completed due to small numbers. Results: A total of 30 out of 79 participants responded to the survey, for a response rate of 38%. Respondents generally ranked patient and family related barriers highest. For instance, patient difficulty accepting prognosis or indicating a desire to be “aggressive” was rated by 69% of respondents as an extremely or very important barrier to initiating EOL discussions. Sixty-three percent of respondents also rated patients’ inflated expectations of further cancer treatment benefit as a very or extremely important barrier to discontinuing active cancer-directed therapies. Patient or family refusal for referral was rated by 47% of respondents as a very or extremely important barrier to early palliative care referral. The majority ( > 85%) of respondents were very or extremely willing to initiate, lead, and finalize the EOL discussions with patients and their families. Conclusions: Oncologists in this study ranked patient and family related barriers to having EOL discussions above all other barriers. Further work is required to better understand such perceived barriers, and compare them to patient preferences and perceptions about EOL planning and cancer care at the end of life. Targeted interventions to address these barriers could then be developed.
Changing focus: Living with advanced cancer—Development of a palliative care transition project.
Authors: Daeninck Paul Joseph , Stenekes Simone , Carpenter-Kellett Tara , Talylor-Brown Jill , Kristjanson Mark , Loewen Ruth , Gingerich Joel Roger
Published: February 2017

152

Background: The improvement in cancer screening, detection and treatment is changing the illness trajectory and experience for patients. Many cancer patients are living longer with advanced disease as treatment options have expanded. Thus, accurate prognostication is becoming challenging and referral to palliative care programs is often delayed until close to death. This has made the transition to a predominantly palliative approach to care complex to navigate for the health care team, patient and family. Methods: CancerCare Manitoba has undertaken an innovative project “Changing Focus: Living with Advanced Cancer” to enhance communication with primary health care providers (HCPs) and assist patients and caregivers in the transition to a palliative approach to care. The project includes development of an individualized patient treatment summary that provides details of the patient’s cancer treatment and symptoms, identifies the role of the HCPs involved with the patient and family, as well as the expectations for follow up care at the cancer centre and in the community. The transition appointment includes discussion around the treatment summary, standardized follow up care plan, and written information about palliative care, decision making, symptom management, unique issues for caregivers and details about local supports and resources is provided. Results: This presentation will focus on the development and implementation of this project within the cancer centre and throughout the province. Evaluation of this approach is ongoing. Family members and patients will provide feedback using a standardized questionnaire, and ongoing improvement will be built into the evolution of this program. HCPs will also be engaged in evaluation from their perspective. Conclusions: We expect this intervention will allow patients and families better quality of life and possibly improve the interval between the termination of chemotherapy and death.
Integrating outpatient palliative care into a metastatic breast oncology clinic.
Authors: Small Rebecca , Belkora Jeffrey , Jow Alexander , Rabow Michael W. , Majure Melanie Catherine , Melisko Michelle E. , Chien Amy Jo , Rugo Hope S.
Published: February 2017

154

Background: The Advanced Breast Cancer (ABC) program at UCSF aims to improve metastatic breast cancer outcomes through early integration of palliative and oncologic care. Oncologists now routinely refer stage 4 patients to a palliative care physician and social worker. Thus this initiative translates ASCO policy recommendations into clinical practice. We report early results from our development, implementation, and evaluation of this novel program. Methods: To evaluate ABC, we used the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation and Maintenance), and Rogers’ Diffusion of Innovations theory. Results: Reach: From 10/2014 to 6/2015, 43 women participated out of 64 invited. Decliners’ main reason for refusal was to avoid additional appointments. Effectiveness: 36 patients reported improvements in 13 of 15 quality criteria, including care coordination, emotional support, and propensity to recommend the program. 34 patients responded to ESAS, QUAL-E and Steinhauser Spiritualty Screen questionnaires, with improvement in 10 out of 14 outcomes at 1-2 month follow-up. Improvements included reduction of anxiety, improved quality of life, and decreased nausea. Adoption: Early integration of palliative care is complex and requires additional coordination among busy clinicians. To address this, we embedded a palliative care physician in the oncology clinic two half-days per week; relied on an oncology fellow to facilitate ongoing cross-disciplinary collaboration; and leveraged the program coordinator’s capacity for following up on both project and patient issues. We also instituted a monthly team meeting to review patient cases. Implementation: Overall, our program design succeeded. Challenges included how to best communicate about patient prognosis and reason for referral. We also struggled to determine what patient eligibility criteria should trigger a referral. Maintenance: The program is currently sustained by grants and intramural cancer center funding. We are seeking continued investment. Conclusions: The ABC program demonstrates that early integration of palliative and oncologic care is feasible and associated with the psychosocial benefits previously found in efficacy studies.
Distress factors in the determination of palliative care for ethnically diverse women with gynecologic cancer.
Authors: Falae Adebola , Robinson William , Robinson William R.
Published: February 2017

16

Background: Versions of the Distress Thermometer have been used and validated widely, but studies of ethnically diverse populations has been limited. A modifed version of the Thermometer is used to understand factors affecting an African American(AA), inner-city population in order to improve access and utilization of palliative care services in a large, ethnically diverse metropolitan area. Methods: A cross-sectional study of women recieving cancer therapy in New Orleans, LA in 2013-14 was conducted. Subjects completed modified Distress Thermometer surveys which captured levels of distress and assessed predefined factors that could impact distress.Demographics were collected, and descriptive and comparative analyses were performed. Results: 49 Caucasian and 34 AA subjects were analyzed. Overall distress rating distributions were similar between the two groups. AA subjects cited family factors as a cause of distress more often than Causasians. (p < 0.006) AA subjects were also more likely to indicate difficulty with partners and overall lack of support as stressing factors than Caucasians. In subjects who reported distress scores greater than 4, AA subjects cited emotional and physical factors more frequently than Caucasians as a cause for distress. (p < 0.05) 11.11% AA subjects vs 3.57% Caucasians cited spiritual factors as a cause of distress. Conclusions: AA women with gynecologic cancer are more likely to cite familial, emotional, physical and perhaps spiritual factors as factors affecting distress than Caucasian women. These findings could be used to target Palliative Care resources more effectively in an ethnically diverse population.
Hospitalizations and emergency department use in cancer clinical trial patients.
Authors: Nipp Ryan David , Powell Elizabeth , Moy Beverly
Published: February 2017

160

Background: Cancer clinical trials (CTs) often represent the best available treatment for many patients, but little is known about the health care utilization of these patients. We examined correlates of hospitalizations and emergency department (ED) use in cancer CT patients to determine those at greatest risk for these outcomes. Methods: We prospectively collected data on patient characteristics, hospitalizations and ED use among all patients enrolled in cancer CTs at Massachusetts General Hospital in 2014. We calculated the number of hospitalizations and ED visits in the 6-month interval following patients’ CT enrollment. We used linear regression with purposeful selection of covariates to identify factors associated with hospitalizations and ED use. Results: Of 1,218 CT patients (mean age = 58 years; 575 (47%) male), 781 (64%) were married and 851 (70%) had metastatic disease. All cancer types were represented, but hematologic cancers (21%) were most common. Within 6 months following CT enrollment, 519 (43%) and 327 (27%) had at least one hospitalization and ED visit, respectively. At any time during their cancer course, 177 (15%) received a palliative care (PC) consult. Controlling for presence of metastatic disease, PC consults correlated with both hospitalizations and ED visits. Having a hematologic cancer and being unmarried correlated with more hospitalizations and ED visits, respectively. Conclusions: Hospitalizations and ED visits occur in a substantial proportion of cancer CT patients. We need to better understand reasons for these high rates of health care utilization, but the correlations with PC consults suggest that CT patients have unique supportive care needs and that PC services are being targeted to a population particularly in need. [Table: see text]
Characterizing terminal oncology ICU hospitalizations.
Authors: Daly Robert Michael , Hantel Andrew , Polite Blase N.
Published: February 2017

167

Background: Twenty-five percent of Medicare cancer beneficiaries use the ICU in the last month of life, and 8% of cancer patients expire there. Cancer patients who die in the ICU have worse quality of life compared with those who die at home. Terminal ICU hospitalizations also come at high financial cost, accounting for 80.2% of all terminal hospitalization costs. Our hypothesis is that a significant number of oncology patients suffer avoidable terminal ICU hospitalizations. By better characterizing these hospitalizations, we will provide the knowledge backbone for future interventions. Methods: Using data from the University of Chicago (UC) cancer registry, we identified patients who died in UC adult ICU’s in FY2013. Of the 1,388 oncology deaths, 115 were in the ICU. Of those, 73 were established patients having had at least one visit with a UC oncologist. We performed a chart abstraction to identify patient, clinical, and hospitalization characteristics. Results: The average age of this patient population was 64 years and 71% were men. Solid and hematologic malignancies comprised 71% and 29%, respectively. Of the solid malignancy patients, 54% had metastatic disease. The average duration of the patient-oncologist relationship was 693 days, and 77% had their last oncology appointment within 2 months of index hospitalization. The ECOG performance status was ≥ 2 prior to admission in 51% of patients. These patients had an average of 3 hospitalizations and 15 outpatient visits in the year prior to death. Eighty-one percent did not have advance directives and 86% did not have an outpatient palliative care consult. The average duration in the ICU was 8 days, during which 95% did not have an inpatient palliative care consult, 79% were intubated, and 38% had resuscitation attempted. Conclusions: Most cancer patients who died in the ICU had an advanced stage malignancy and/or poor clinical status prior to admission. In addition, a significant number received intubation and resuscitation. Despite evidence of adequate interaction with the healthcare system, most patients had not had a palliative care consult or advance directives. This study will allow for further exploration of the avoidability of terminal oncology ICU hospitalizations to inform future interventions.
A comparison of QOPI metrics in solid tumor oncology clinic with or without concomitant supportive oncology consultation.
Authors: Huo Ran , Scarborough Bethann , Goldstein Nathan , Smith Cardinale B.
Published: February 2017

173

Background: The Quality Oncology Practice Initiative (QOPI) is a voluntary quality measurement and improvement program designed to assess practice performance for a series of consensus based and evidenced based measures. Several measures within QOPI pertain to the use of supportive care in the treatment of cancer patients. We hypothesized that patients receiving integrated oncology and palliative care (intervention group) may meet a higher number of quality metrics as compared to patients receiving oncologic care alone (control group). Methods: We conducted a retrospective chart review of patients treated between June of 2013 to June of 2015 from our intervention group and matched these to similar patients within the control group based on tumor type and date of initial visit to oncologic care. We performed bivariate analysis comparing differences in supportive care QOPI measures among the intervention and control group. Results: We identified a total of 200 patients. Patients in the intervention group were younger (p = 0.27) and female (p = 0.21). Among the QOPI metrics, pain was significantly better addressed (p < 0.001) among the intervention group. No significant difference was detected in other QOPI metrics. Of note, the intervention groups had significantly higher rates of enrollment in hospice (p < 0.001) and significantly lower rates of death within the hospital and/or the ICU (p = 0.04). Conclusions: Integrating outpatient palliative care consultation along with standard oncologic care did improve pain being adequately addressed, improved hospice utilization and decreased death within the hospital and ICU. Many of the supportive oncology QOPI metrics can be satisfied by a prompt from the EMR, however adequately addressing pain requires specialized skills. These data support the need for increased primary palliative education regarding pain management for oncologists.
Advance directives: Cancer patients’ preferences and family-based decision making.
Authors: Li Xing , Lin Zhi-Huan , Hong Ying-Fen , Ma Xiao-kun , Wu Dong-hao , Xing Yan-Fang , Wu Xiang-yuan , Lin Qu
Published: February 2017

18

Background: Advance directives (ADs) are a sensitive issue among traditional Chinese people, who usually refrain from mentioning this topic until it is imperative. Medical decisions for cancer patients are made by their families, which might violate patients’ personal will. This study was aimed to examine the acceptance of ADs among Chinese cancer patients and their families and patient participation in this procedure. Finally, to analyze the moral risk involved. Methods: Participants included 412 adult cancer patients from 9 leading hospitals across China. An AD was introduced to the main decision makers for each patient; if they wished to sign it, the AD would be systematically discussed. A questionnaire was given to the oncologists in charge of each patient to evaluate the interaction between families and patients, patients’ awareness of their disease, and participation in an AD. Results: A total of 246 patients and their family members rejected systematic discussion of AD, the majority (95.5%) of whom were under anti-cancer treatment. An additional 166 patients or their families accepted the concept of an AD and signed an AD to give up invasive treatment. This decision was make shortly after termination of anti-cancer therapy. Correlational analysis revealed that patients living in villages and who were subordinate members in their families tended to accept an AD. Of these, only 24 patients participated in the decision making. Correlational analysis revealed that patients with a better financial situation, living in cities, and superordinate status in their families tended to participate in the AD discussion, as well as those who usually made medical decisions themselves. Nearly all the patients deciding their own AD knew their entire situation, including diagnosis and prognosis. For 101 patients, anti-cancer therapy was ended prematurely, with as many as 37 patients not told about their potential loss of health interests. Conclusions: ADs were widely accepted among Chinese cancer patients when anti-cancer therapy was terminated. Most cancer patients were excluded from the discussion of an AD. Thus, AD could be formally introduced to the family of Chinese cancer patients after termination of anti-cancer therapy.
Survival among cancer patients undergoing opioid rotation to methadone as compared to other opioids.
Authors: Reddy Akhila Sunkepally , Yennu Sriram , Schuler Ulrich S. , De la Cruz Maxine Grace , Wu Jimin , Liu Diane D , Bruera Eduardo
Published: February 2017

183

Background: Recent studies have reported that methadone has antineoplastic activity. Other studies have associated methadone with lower overall survival in patients with chronic pain. Methadone is the most frequent opioid chosen for purpose of opioid rotation (OR) in cancer patients experiencing refractory pain or opioid induced neurotoxicity. There is no data available on the association of methadone with overall survival in cancer patients. Our aim was to compare the characteristics and overall survival in cancer patients in methadone group with other strong opioid group. Methods: In this ad hoc analysis, we reviewed 2471 consecutive patient visits to the supportive care center of a tertiary cancer center in 2008 for ORs from strong opioids to methadone or other strong opioids with a follow-up visit within 6 weeks. Information regarding demographics, Edmonton Symptom Assessment Scale (ESAS), and morphine equivalent daily dose (MEDD) were collected. Successful pain response was defined as 2-point or 30% reduction in pain score. Kaplan-Meier curves were used to evaluate survival. Results: Of the 102 eligible patients, 54 underwent OR to methadone and 48 to other strong opioids. The median age was 56 years, 56% were male, and 81% had advanced cancer. There were no significant differences between the methadone group and the other opioid group in patient characteristics, performance status, MEDD, and ESAS scores. Although both the groups showed significant pain response, methadone group (72%) had a significantly higher pain response as compared to the other opioid group (65%; P = 0.04). The Kaplan-Meier curves revealed no significant difference in overall survival (OS) between the methadone group and the other opioid group [median OS: 5.2 months (95% CI 3.64-7.41) vs. 5.9 months (95% CI 2.6-9.2); P = 0.89]. Conclusions: We observed no significant difference in overall survival in cancer patients in methadone group as compared to other opioids. Further validation studies in a larger sample are warranted.
Thromboembolic events in hospitalized cancer patients: Impact on stay duration and cost for four major cancer localizations.
Authors: Scotte Florian , Vainchtock Alexandre , Martelli Nicolas , Borget Isabelle
Published: February 2017

186

Background: Cancer patients represent an at-risk population for Venous Thromboembolic Events (VTE). Our study aimed to evaluate the impact of VTE on the length and cost of hospital stay in French patients hospitalized for breast cancer (BC), colon cancer (CC), lung cancer (LC) or prostate cancer (PC). Methods: The French national hospital database (PMSI) and the disease-specific ICD-10 codes were used to identify BC, CC, LC or PC patients diagnosed in 2010 who were hospitalized with a VTE during the following two years. We selected stays during which a VTE occurred but was not the main reason of hospitalization (cancer was classified as primary/related diagnosis and VTE as significant associated diagnosis). Those stays were matched and compared to similar stays (same cancer and same reason for hospitalization) without VTE. Costs were calculated using the French official tariffs, from the perspective of the third-party payer. Results: We identified 214 stays for breast cancer during which a VTE occurred and was classified as significant associated diagnosis, 843 stays for colon cancer, 1301 for lung cancer, and 126 for prostate cancer. The comparison between those stays and similar stays without VTE showed significant increase of hospital stay duration in patients experiencing VTE. Median duration rose from 4 to 7 days in BC patients, from 8 to 16 days in CC, from 2 to 9 days in LC and from 6 to 10 days in PC. Consequently, the median expenditure per stay increased by 37% in BC patients with VTE (up to € 5,518), by 61% in CC (up to € 9,878), by 202% in LC (up to € 7,308) and by 22% in PC (up to € 6,200). Conclusions: When occurring during hospitalization, VTE made cancer management much heavier: patients faced prolonged hospital stays whereas healthcare system faced significant additional cost. Better prevention and follow-up measures could reduce this burden, and benefit both patients and hospitals. [Table: see text]